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THE NEW PUBLIC HEALTH 



THE MACMILLAN COMPANY 

NEW YORK • BOSTON • CHICAGO • DALLAS 
ATLANTA • SAN FRANCISCO 

MACMILLAN & CO., Limited 

LONDON • BOMBAY • CALCUTTA 
MELBOURNE 

THE MACMILLAN CO. OF CANADA, Ltd. 

TORONTO 



The New Public Health 



BY 



HIBBERT WINSLOW HILL, 

M. B., M. D., D. P. H. 
Late Director, Division of Epidemiology, Minnesota State 
Board of Health, and later Executive Secretary, Minne- 
sota Public Health Association, now Director, 
Institute of Public Health; and M. O. H. t of 
London, Canada; Professor of Public 
Health, Western University. 



Bew J?orft 

THE MACMILLAN COMPANY 

1916 

All rights reserved 






Copyright, 1916, 
By THE MACMILLAN COMPANY. 



Set up and electrotyped. Published February, 19x6. 



Nortocotr $r«8 : 
Berwick & Smith Co., Norwood, Mass., U.S.A. 



fi.- 



FEB 3 1916 

©JLA418671 



PEEFACE 

The conceptions of health, public and private, held by 
our ancestors and, until very lately, by ourselves, have 
undergone gradual revision, not to say revolution, in the 
last twenty years; changing most radically perhaps in 
the last ten. The Minnesota State Board of Health in 
1911 designated the writer, then in charge of the Divi- 
sion of Epidemiology of that Board, to present the 
modern conceptions to the medical profession and to the 
public. A series of articles, which appeared monthly 
during 1912 in the Journal-Lancet of Minneapolis, was 
the outcome. These articles were furnished by the 
Journal-Lancet to 1,100 newspapers in the United 
States, and, during the latter half of the series, to fifty 
newspapers in Canada. Finally they were reprinted in 
book form at the end of the year. So cordial was their 
reception, that a revision and expansion of the articles 
thus first issued has been undertaken here. 

The writer, in expressing his great personal debt to 
the State Board of Health of Minnesota for making 
possible this beginning and to the Board of Governors 
of the Institute of Public Health of London for its 
liberal support and continuation, would mention par- 
ticularly Dr. W. A. Jones and Dr. H. M. Bracken, re- 



PREFACE 

spectively president and secretary of the Minnesota 
State Board of Health, Drs. B. M. Merrill and C. F. 
More, members of the Censorship Committee of that 
Board, and Mr. W. L. Klein, publisher of the Journal- 
Lancet, for their advice, deep personal interest, and 
cordial co-operation. To Dr. F. F. Wesbrook, now 
President of the University of British Columbia, then 
Director of the Minnesota State Board of Health 
Laboratories, to Dr. A. J. Chesley, then a colleague, 
now the writer's successor in the Division of Epidemi- 
ology, to Professor F. H. Bass, ex-Director of the Divi- 
sion of Sanitary Engineering of the Minnesota State 
Board of Health, to Mr. Christopher Easton, at one 
time Secretary of the Minnesota Anti-Tuberculosis 
Association, to Dr. J. P. Sedgwick of the Medical De- 
partment of the University of Minnesota, and to Pro- 
fessor S. Quigley of the Department of Pedagogy of 
the same University, the writer acknowledges with 
pleasure most friendly and valuable consultation on the 
more technical portions. 

It is not possible to list all who have aided the writer 
directly or indirectly in this work; still less possible 
would it be to attempt to list those whose appreciation 
and good wishes made the work a pleasure. But it 
would be unseemly to omit reference to one other, who 
was unconnected with the official family either in Min- 
nesota or in London. The great reconstructing force 
in Public Health has been bacteriology, but the applica- 
tion of the laboriously sought out and, to Public Health 



PREFACE 

principles, in general, often barren, work of the Bacteri- 
ologist, must be acknowledged as due to an administrator 
of keen insight and logical mind, Dr. Chas. V. Chapin 
of Providence, whose " Sources and Modes of Infec- 
tion " marks the real beginning of scientific public 
health in America. 

That this book may further aid in giving to all who 
read it a definite view of the chief problems of public 
health, and of their chief solutions, is the aim of the 
writer ; that it may prove a satisfaction to many friends, 
his hope. 



CONTENTS 



CHAPTER PAGE 

1 DEFINITIONS 1 

Summary 5 

II THE OLD PRINCIPLES AND THE NEW ... 7 

The Revolution 7 

The Old Teachings 9 

The New Ideas 12 

Environment 14 

III INFECTIOUS DISEASES 17 

Facts 17 

(a) Sources of Infectious Diseases . . .21 

(b) Routes of Infectious Diseases ... 23 

(c) Control of Infectious Diseases ... 24 

IV WHY DO ANYTHING? 26 

How Big a Problem Is It? 27 

Who Keeps the Infectious Disease Going? . 28 

Why and How are Women Responsible? . . 29 

Present Attempts 29 

Radical Changes in Social Conditions the 

Real Solution 30 

V NON-INFECTIOUS DISEASES 33 

Speculations 33 

Physical Perfection 35 

The General Problem 36 

The Present Situation 39 

Immediate Possibilities 42 

Education 45 



CONTENTS 

CHAPTER PAGE 

Medical Supervision of Schools 48 

Summary 50 

VI EDUCATIONAL MECHANISM 53 

Summary 61 

VII THE OLD PRACTICE AND THE NEW .... 63 

Epidemiology 63 

Comparative Methods 65 

The New Emergency Epidemiology .... 69 

Stopping a "Primary" Epidemic 71 

Stopping " Secondary " Outbreaks . . . 73 

Finding the Unknown Cases 75 

Summary 77 

VIII THE NEWEST PRACTICE 79 

Concurrent Epidemiology 79 

Future Applications 84 

Chief Infectious Diseases, Classified by 

Routes 88 

The New Program 91 

IX INDIVIDUAL DEFENSE 95 

Public Defense and Private 95 

The Preventability of the " Preventable " 

Diseases 96 

"Dodging Infection" 100 

Contact-Infection 101 

Placard for Schools 107 

Summary 112 

X COMMUNITY DEFENSE 114 

The Public Health Engineer . . . . . .114 

Summary 122 

XI COMMUNITY DEFENSE 124 

The Public Health Laboratory 124 

Summary 131 



CONTENTS 

CHAPTER PAGE 

XII COMMUNITY DEFENSE 133 

The Public Health Statistician 133 

Statistics as They Will Be 134 

Statistics as They Abe 138 

Summaby 147 

XIII ADMINISTRATION 148 

Summaby 156 

XIV COMMUNITY DEFENSE APPLIED 158 

Tubeeculosis in Genebal 158 

Human Tuberculosis 159 

The Abolition of Cattle Tubeeculosis feom 

the Human 163 

The Abolition of Human Tubeeculosis . . . 163 
Summaby 170 

XV THE CONTROL OF DIPHTHERIA, SCARLET 

FEVER AND MEASLES 173 

Summaby 176 

XVI VENEREAL DISEASES 178 

XVII THE CONCLUSION OF THE WHOLE MATTER . 182 

The Doing of It 182 

The Chief Objections 185 

Populab Fallacies 189 

New Fashioned Quarantine 190 

Summaby 192 

APPENDIX I. Condensed Data on Infectious 
Diseases 195 

APPENDIX II. Syllabus of Public Health 
Teaching 197 



THE NEW PUBLIC HEALTH 

CHAPTER I 
DEFINITIONS 

Public Health is a term which includes all knowl- 
edge and all measures tending to (a) foster health or 
(b) to prevent disease. 

These two objects are far from identical. True, cer- 
tain personal measures to promote health, classed under 
hygiene, i.e., proper care and cultivation of, say, the 
muscles, necessarily also avoids those " diseases/' which 
may result from neglect or misuse of those muscles ; in- 
cidentally, perhaps, of other parts of the body also. To 
care for properly and develop sight to its highest effi- 
ciency necessarily includes eliminating the train of 
evils connected with eye strain. But such cultivation 
of the body forces to secure high efficiency will not and 
cannot prevent those accidents or diseases which origi- 
nate from outside sources. A bullet will travel equally 
as far through the soldier who is physically perfect as 
through him who is a physical wreck. 

Public Health may be divided into Hygiene and 

Sanitation. Hygiene deals with the individual and 

l 



2 THE NEW PUBLIC HEALTH 

his physical perfection. The causes and sources of 
those diseases which come from the outside, from the 
surroundings of the individual, are dealt with under the 
term Sanitation. Just as Hygiene deals with meas- 
ures which (a) promote health and, some of them (b) 
prevent disease, so Sanitation also presents two sub- 
divisions, the measures, dealing with surroundings, 
which intrinsically (a) promote health or (b) prevent 
disease. Thus, proper ventilation, while securing the 
best available conditions for the body so far as atmos- 
pheric surroundings are concerned, necessarily elimi- 
nates those " diseases " which might arise from the re- 
action of the body to " poor ventilation/' and so far 
Sanitation and Hygiene are intimately interdependent. 
But good ventilation, although invaluable to the gen- 
eral welfare and efficiency of the body, has no necessary 
relation to the elimination of certain outside injurious 
forces, such as lead poisoning or alcoholism or accidents 
or invasions of the body by micro-organisms. Each of 
these must be met by specific measures, adapted to the 
elimination of the particular factor involved. More- 
over, such specific measures will eliminate the specific 
trouble, whether such general physical efficiency and 
high health as may be secured through good ventilation 
be secured or not. 

The greatest advance made of recent years in public 
health is the generalization from such facts, long 
known in detail, that measures promoting bodily health 
and efficiency do not necessarily eliminate those ex- 



DEFINITIONS 3 

ternal and insidious factors of disease by invasion from 
without, particularly of the invaders which produce the 
infectious diseases. 

A third relationship, long believed and taught as 
existing between the measures for promoting health and 
those for eliminating disease, is fast losing its alleged 
importance. This belief is that which regards high 
health as not indeed abolishing infection, but as con- 
ferring an immunity against infectious diseases. It is 
beginning to be recognized that as " good ventilation " 
does not eliminate " eye strain," as good lighting does 
not correct " poor ventilation," so all through hygiene 
and sanitation specific troubles must be met by specific 
measures directed specifically against the real specific 
cause of that trouble. Taught for, lo these many years, 
that general cleanliness is a protection against disease, 
we are beginning to realize that only a specific cleanli- 
ness, that which actually eliminates disease germs, is of 
real value for this purpose; taught also that general 
high health protects against disease, we are beginning 
to understand that the only form of bodily condition 
which secures this end is the possession by the body of a 
specific protection against each specific disease. 1 Even 
should we admit that perfect health may theoretically 

i It is far from certain that the process of securing such 
specific immunity through an attack of the disease in question 
does not involve permanent damage to the body incompatible 
with the subsequent attainment of the highest physical perfec- 
tion. 



4 THE NEW PUBLIC HEALTH 

prevent the inroads of smallpox or typhoid fever or pneu- 
monia or colds, we would also have to admit that such 
high health is very readily upset, by a chill, a missed 
dinner, a day's overwork, a temporary indigestion; 
and since this is so, that the protection against infec- 
tion afforded by such high health, if it exist at all, is too 
vague and uncertain, too subject to sudden alterations 
and even complete loss, to be worthy serious considera- 
tion as a real factor in the control of disease, in ordi- 
nary life. The value of high health, of hygiene, lies 
in the physical efficiency and bodily comfort which it 
bestows ; in the sense of well being, in the energy, alert- 
ness and keenness which result from it. That it does 
not protect against infection, that it actually indirectly 
contributes to infection from the very fact that the 
energy and alertness it bestows take its possessor out 
where infection lies awaiting him, does not lessen its 
real value, but only makes the removal of the infection 
itself an even more important duty to the race. The 
man of " torpid liver " and bleary eye, the muscular 
wreck, lacks that vigor and aggressiveness which carry 
the possessor of high health out into the busy haunts of 
men and women ; and to the extent that he escapes con- 
tact with his fellows, he tends to escape infection, just 
as the invalided soldier escapes the effects of bullets by 
not encountering them. 

To hold that weaklings only, or principally, suffer 
from diseases of this nature is to hold a view which 
represents a complete reversal of the facts; indeed, if 



DEFINITIONS 5 

this view were true, infectious diseases would long since 
have weeded out all such weaklings and left a race of 
physically perfect giants, free from all diseases be- 
cause of their exceeding physical perfection; whereas 
exactly the contrary is true, and we hear the cry every- 
where that physical degeneracy is the bane of modern 
citizenship. Scarcely one-fifth of the young men ex- 
amined for the U. S. army meet the much modified 
army requirements as to physique; moreover, that se- 
lected fifth, disciplined, exercised, fed and cared for at 
the highest level of hygiene that we know succumbs to 
infections quite as easily as their rejected brothers; and 
modern armies find high health and physical develop- 
ment so little a protection against these infections that 
every new specific, like vaccination, is seized upon 
eagerly to take its alleged place. Surely it is time to 
cease misleading the public and ourselves with a will-o'- 
the-wisp since the very teachers that lend their weight 
to the doctrine find in practice that no high health they 
can. compass for their trained armies protects those 
armies in any adequate sense. 

STJMMAEY 

Modern Public Health recognizes that health means 
much more than the mere absence of disease ; and under 
Hygiene classes all measures to secure the best internal 
workings of the human frame to keep it at its best; 
thus eliminating the internal poisonings, and the re- 
sults of deprivations and excesses which produce cer- 



6 THE NEW PUBLIC HEALTH 

tain diseases or disabilities. But it recognizes further 
that surroundings, through direct action on the body, 
perfect or imperfect, may injure or destroy the best 
just as the worst ; and under Sanitation, strives to pro- 
vide surroundings which may eliminate external condi- 
tions leading to disease or injury. 

The chief advance of recent years is that which recog- 
nizes the specificity of cause and effect, both in Hygiene 
and in Sanitation; and meets each separate source or 
cause of each such trouble with a specific measure to 
prevent it. 

Against the visible outside causes of disease, those 
causes which can be seen and recognized by every one, 
(the chemical poisons, accidents, etc.), the weapons are 
education and elimination or proper handling of those 
causes, if they cannot be eliminated. 

Against the invisible and, to the general public, un- 
recognizable causes which produce the infectious dis- 
eases, the warfare must necessarily be directed to their 
elimination, under such preliminary education as will 
permit the establishment of the necessary mechanisms. 



CHAPTEE II 
THE OLD PKINCIPLES AND THE NEW 

THE REVOLUTION" 

The statement that there is a " New Public Health " 
may shock those who, although familiar with recent 
changes in scientific thought, yet have not fully realized 
what those changes mean; but the shock will be far 
greater to those who have not appreciated that changes 
were going on. 

The purpose of the writer is to formulate for both 
groups, the unconscious progressive and the unconscious 
conservative, a brief statement of the essential prin- 
ciples of modern professional public health work relat- 
ing to the prevention of disease. To those who may 
feel skeptical as to the fairness of this exposition, the 
writings of Chapin, the great American pioneer of 
modern public health, of E. O. Jordan, and of M. N. 
Baker, may be offered as bearing directly upon these 
questions, while the whole of modern technical public- 
health literature may be offered as indirect evidence. 
Since the infectious diseases constitute the chief as well 
as the best understood group of preventable diseases or 
causes of death and disability, the infectious diseases 
are here chiefly discussed. 



8 THE NEW PUBLIC HEALTH 

The old principles have merged gradually into the 
new, in keeping with the experiments, observations, 
and conclusions of many investigators in many indi- 
vidual sciences related to general public health. 
Within professional public-health circles, bacteriology, 
clinical observation, and mathematics have furnished 
most of the reconstruction. The bacteriologist, the epi- 
demiologist, and the vital statistician, sometimes work- 
ing together, more often alone, in the dark and even 
at cross purposes, have nevertheless all reached the same 
point, and to-day each finds his co-workers beside him. 
Much of the work done has consisted in clearing away 
the fallacies built up by tradition, but construction- 
work has gone on also, and it is now possible to formu- 
late the results. 

The essential change is this: The old public health 
was concerned with the environment; the new is con- 
cerned with the individual. The old sought the sources 
of infectious disease in the surroundings of man; the 
new finds them in man himself. 

The old public health sought these sources in the air, 
in the water, in the earth, in the climate and topog- 
raphy of localities, in the temperature of soils at four 
and six feet deep, in the rise and fall of ground-waters ; 
it failed because it sought them, very painstakingly and 
exhaustively, it is true, in every place and in every 
thing where they were not. 

The new public health seeks these sources — and 
finds them — amongst those infective persons (or ani- 



OLD PRINCIPLES AND NEW 9 

mals) whose excreta or other constituents or body con- 
tents enter the bodies of other persons. 

The old public health failed to find the sources of in- 
fection; it also failed in most instances to find the 
routes of transmission. It is true that public water- 
supplies were detected as at times transmitting infec- 
tion ; but milk was hardly suspected twenty years ago ; 
flies (and other insects), suggested in 1887, 1 were not 
seriously considered until the Spanish- American war; 
mouth-spray 2 and hands have been only recently recog- 
nized as important. On the other hand, dirty clothes, 
bad smells, damp cellars, leaky plumbing, dust, foul 
air, rank vegetation, swamps, stagnant pools, certain 
soils, smoke, garbage, manure, dead animals, in fact 
everything physically, sensorially, esthetically, or 
psychically objectionable, were lumped together as " un- 
sanitary " without much distinction of " source " or 
" route/' and were regarded as a sort of general " cause 
of disease " to be condemned wherever found, " for fear 
of epidemics." 

THE OLD TEACHINGS 

It was taught that infectious diseases " generated " in 
the foul, ill-smelling, unventilated, sunless hovels of the 
slums. In the vogue of those days, " the slum-dwellers 

i Wm. H. Welch : Address at the Annual Meeting of the Medi- 
cal and Chirurgical Faculty of Maryland 1887, quoted in Sewage 
and Local Drainage. — Waring, 1889. 

2 By this is meant the fine droplets thrown out from the mouth 
in speaking, singing, laughing, sneezing, coughing, etc. 



10 THE NEW PUBLIC HEALTH 

live like pigs, and thereby invoke the coming of small- 
pox, scarlet fever, typhoid fever, diphtheria." When 
these diseases invaded the home of the well-to-do, where 
this explanation was not seemly, a pinhole leak in some 
plumbing fixture accounted amply for diphtheria; rot- 
ten potatoes, forgotten in a dark corner of the cellar, 
for typhoid fever; scarlet fever was traced to a letter 
bearing " scales " from a friend who had had the dis- 
ease months before; smallpox to unpacking books used 
by a patient a quarter of a century previously ; manure 
piles gave rise to cholera; and dampness to malaria, 
which was not recognized as transmissible at all. Tel- 
low fever originated in impure water and was directly 
transmitted from person to person — a typical example 
of intense direct contagion; tuberculosis was non-infec- 
tious and hereditary ; bubonic plague was banished from 
the Egyptian Cairo " simply by improving the ventila- 
tion of the city" (!) 3 

Eemedial and preventive measures, based on such 
beliefs in the omnipotence of environment, naturally 
sought to remodel the lives and immediate home sur- 
roundings of the whole population to conform with a 
vast array of alleged " sanitary laws of health." Yet 
he who seeks for a scientific demonstration of the rela- 
tions existing between disobedience of these " sanitary 
laws " on the one hand, and the incidence of disease 
and death on the other, will find only a " twilight zone " 

3 Parke's Hygiene, 1891; eighth edition. This was a standard 
work of twenty-five years ago. 



OLD PKINCIPLES AND NEW 11 

in which move vague shadows of traditional fear, shad- 
ows which, on probing, fade mistily away. 4 

While admitting freely that almost any item of an 
environment may act as a route of infection, at odd 
times, or under peculiar conditions, the New Public 
Health is not worried by elaborate theoretical possibili- 
ties, but concerns itself earnestly with practical proba- 
bilities. The occasional, unusual, bizarre routes of in- 
fection in the 1 per cent, of cases, do not distract its 
attention from the usual, practically constant, simple, 
ordinary routes concerned in the 99 per cent. 
Its main postulate is that the routes of infection are 
simply the routes of infected bodily discharges, which, 
again, are identical with the routes of ordinary unin- 
fected discharges in ordinary life; and that if the 
99 per cent, of commonplace cases are prevented, the 
1 per cent, will not occur at all. Too often attention 
has been riveted on extreme precautions to avoid the 
1 per cent., and no precautions worthy of the name 
have been directed to avoidance of the 99 per cent. 

The old style " sanitary inspector " was expected to, 
and usually did, " condemn " everything in sight, from 
the garbage pail at the back door to the plumbing in the 
bath-room. But disease continued, because he was con- 
demning, as a rule, so far as health was concerned, 
things largely " incompetent, irrevelant and imma- 
terial." What availed it that the garbage-pail was 
emptied every day or a vent-pipe placed on the bath- 

4 See Journal-Lancet of July 15, 1914. 



12 THE NEW PUBLIC HEALTH 

water waste-trap, if the milkman delivered scarlet-f ever- 
infected milk at the door, or an unrecognized case of 
measles sat next the children at school ? 

The wooden knight of Alice in Wonderland who 
carried a mouse trap on horseback because mice might 
some day infest his horse, while riding so badly that he 
continually fell off on his head and was as continually 
in process of being restored to his saddle by kind 
friends, furnishes the most kindly yet realistic satire 
on prevailing public-health methods that could well be 
devised. 

THE NEW IDEAS 

The New Public Health sees in the garbage-pail 
merely a place where flies are fed and, possibly, bred. 
But the flies cannot carry infection if infected dis- 
charges are not accessible to them. 

The Old regarded the garbage-pail as in itself and by 
itself intrinsically bad, disease-producing and deleteri- 
ous to health. This, notwithstanding that employes in 
garbage-collection, garbage-destruction or garbage-ren- 
dering work average as healthy a body of men as any 
others of similar status. 

" Defective plumbing," such a nightmare twenty 
years ago, has been conclusively shown to have nothing 
to do with disease-generation or disease-propagation 
whatever, unless perchance there be actual gross leak- 
age of infected sewage. The employees connected with 
great sewage systems, even those continually employed 



OLD PKINCIPLES AND NEW 13 

in the great sewers of large cities, average well, like 
garbage workers, as to incidence of disease amongst 
them. , ^ 

The unventilated front parlor could not produce 
tuberculosis in a hundred years; diphtheria does not 
develop from the family well despite many a well-meant 
tirade on its evils; and typhoid fever, in sand or clay 
areas, is but seldom properly traceable to that source, 
either. Stagnant or old, longstanding water, is to this 
day often considered responsible for typhoid, despite 
the definite knowledge that no system of purification of 
typhoid-infected water is more reliable than impound- 
ing, which is merely keeping it standing ! 

The modern public health man cares nothing, so far 
as restriction of disease and death is concerned, for the 
dirty back yard or the damp cellar in themselves, but 
only as they may enter into the transmission of infected 
discharges. Then, at once, they become of vital impor- 
tance. The sanitary inspection of the modern sani- 
tarian, so far as relates to infection, begins and usually 
ends with the search for (a) the infected individual; 
(b) the routes of spread of infection from that indi- 
vidual ; (c) the routes of spread of the ordinary excreta 
of ordinary uninfected individuals to the mouths of 
their ordinary associates in ordinary life. These latter 
are sought for, not because of danger from such unin- 
fected discharges, but rather because infected dis- 
charges, introduced into and following the same well- 
beaten paths, will necessarily reach the same mouths. 



14 THE NEW PUBLIC HEALTH 

To locate all the infective persons and to guard all their 
discharges would be wholly sufficient and is the ulti- 
mate goal of modern preventive measures, but since this 
cannot always be done perfectly, it is well to guard also 
the routes which unlocated infection may take. 

ENVIRONMENT 

Has environment, then, nothing to do with infec- 
tious diseases ? Environment acts in two ways : First, 
unequivocally and without reserve, such environments 
as permit or encourage or, still worse, necessitate the 
exchange of human excreta in ordinary life, contribute 
in the long run to the spread of disease since they in- 
sure a similar exchange of infected excreta so soon as 
the latter are introduced. 5 Let us take one environ- 
mental evil, overcrowding, as an example. Overcrowd- 
ing, if combined with lack of discipline and order, and 
lack of facilities for washing, especially for the washing 
of hands, contributes to the spread of infectious dis- 
eases; but not in itself; nor at all, unless infection be 
introduced into the community. Then overcrowding, 
because it tends to insure exchange of human excreta, 
tends also to insure that the infection will spread rap- 
idly and extensively. But overcrowding, if the over- 
crowded be disciplined, intelligent, and take proper pre- 
cautions to avoid exchange of excreta, does not necessi- 

s An excellent exposition of this effect of environment on the 
spread of disease is given by Chapin in the Report of the Provi- 
dence Health Department for 1910. 



OLD PRINCIPLES AND NEW 15 

tate the spread of infection, even if it be introduced. 
On the other hand, infection may spread, and fre- 
quently does, without overcrowding, if the essential 
factor of such spread exist, i.e., the transmission of in- 
fected excreta. 

Second. Environments that are bad from a physi- 
ological standpoint (bad for the body, regarded as a 
delicate biological machine) are often held to act in 
spreading infection indirectly by " depressing vitality " 
to an extent which makes infection, if received, more 
likely to develop (and if it develop, more successful in 
injuring the body). It must be said, however, that the 
evidence on this point, except perhaps that relating to 
tuberculosis and pneumonia, is very slight. It is a 
debatable question whether or not overcrowding " de- 
presses vitality " in the direction of increasing suscepti- 
bility to infectious diseases, whatever its effect may be 
in encouraging " general debility/' It is a very de- 
batable question whether or not " poor ventilation/' to 
which the effects of overcrowding are often attributed, 
can or does " depress vitality " in the direction of les- 
sening resistance to infectious diseases, whatever bad 
effects it may have on mental vigor or physical activity. 
It is true that there is evidence that such environments 
as lead to extremes (beyond the limits of compensatory 
adjustments by the body forces) of mal-nutrition, of 
temperature, of fatigue, and of alcoholism, probably 
may have an effect in insuring the development of infec- 
tion, which under better conditions might be negatived 



16 THE NEW PUBLIC HEALTH 

by the body forces. Especially may these forms of bad 
physiological environment be influential when the dose 
of infection is small, infrequent, or low in virulence, 
for it is conceivable that under good environment the 
body might " throw them off more readily." But star- 
vation, unsuitable temperature, fatigue, alcoholism, 
alone or together, cannot induce infection, nor will the 
converse conditions, alone or together, offset the effects 
of infection when the dose is large or frequently re- 
peated or of high virulence. 



CHAPTER III 
INFECTIOUS DISEASES 

FACTS 

It would appear, then, that environment as affecting 
bodily functions has little to do directly with the inci- 
dence of most of the specific infections/ notwithstand- 
ing that nutrition, temperature, fatigue, and alcohol- 
ism are generally credited with some effect, especially 
in pneumonia and tuberculosis. 

Damp, cold, and fatigue perhaps precipitate the 
pneumonias, although the relation is not clear, and of 
course no such effect is observed unless one of the in- 
fective agents be present. The environments if there 
be such at all, that precipitate tuberculosis constitute a 
problem as yet unsolved. Very much is widely be- 
lieved, and even more is freely taught, concerning this 
subject, but the evidence is tangled and often contra- 

i The terms contagious and infectious were formerly carefully 
used and carefully distinguished. Modern writers, however, fail 
to find any useful or basic significance in " contagious " as con- 
trasted with " infectious." Hektoen, in Osier's Modern Medicine, 
discards " contagious " and " contagion " entirely. 

In these articles " infectious " is used to mean " transmissible '* 
or "communicable." 

17 



18 THE NEW PUBLIC HEALTH 

dictory. " Poor ventilation/ ' dust, dampness, etc., 
have all been accused, but very little has been proved 
concerning the real factors actually at work or their 
mode of operation. In the other infectious diseases the 
effects even of extremes of the above factors are but 
rarely definitely recognizable. 

Smallpox is contracted or escaped in exact ratio to 
the degree of exposure acting in opposition to the de- 
gree of specific immunity. No other known environ- 
mental factor, even acute alcoholism, is recognized as 
influential. 

One thing, and one thing only, is absolutely estab- 
lished, namely, that tuberculosis, microbic pneumonia, 
and the other infectious diseases will develop under 
almost any circumstances if the dose of infection be 
large enough, virulent enough, or sufficiently repeated. 
Tuberculosis, microbic pneumonia, and the other in- 
fectious diseases will not develop under any circum- 
stances without such infection. 

Hence it must be evident that the sine qua non of all 
infectious diseases are their respective agents, and that, 
since the chief sources (infective persons) of these are 
known, the most logical efforts are those which concen- 
trate on the prevention of the dissemination of these 
agents from these sources. 

This is tenable, not only in theory, but in practice, 
and presents an infinitely simpler administrative prob- 
lem than that presented by the older hypotheses, — not 
only in the " minor " infectious diseases, where these 



INFECTIOUS DISEASES 19 

principles have been practically accepted by all, but 
even in tuberculosis itself. 

Thus, if " general environment " be the great factor 
in tuberculosis, the hundred million people of these 
United States must have each his or her own individual 
environment brought up to and kept at some standard- 
level designed to maintain each individual in his or 
her own alleged " highest state of health." 

If, however, the infectiveness of the disease be the 
great factor, only 200,000 people (the actively infective 
cases) need this supervision in the United States, and 
they need it, not for the improvement of their " general 
environment," but merely to prevent them from infect- 
ing others. This problem, even numerically, is but one 
five-hundredth the magnitude of the other. Consider 
the utterly impracticable expense and difficulty of the 
attempt to insure only the four quoted factors, — good 
food, proper temperatures, temperance, and repose, — 
to one hundred million people (to say nothing of the 
other " factors of safety " called for by those who lay 
chief emphasis on control of environment, i.e., abolition 
of foul air, smoke, dust, damp cellars, bad smells, dirty 
back yards, etc.), and contrast with this the expense of 
supervision of two hundred thousand people merely to 
the extent of confining their infective discharges to 
themselves. 

Further consider that the same official mechanism 
which could control the tuberculous could also handle 
with but slight expansion the infectious persons need- 



20 THE NEW PUBLIC HEALTH 

ing supervision for the prevention of all the other infec- 
tious diseases, except the venereal, as well as the infec- 
tive tuberculous. Remember also that improvement 
of the "general environment/' allowing that its effec- 
tive achievement were conceivable, could not be ex- 
pected to have any noteworthy effect on most of these 
other infectious diseases, even though it had some on 
tuberculosis. 

Need any more be said to indicate the superiority of 
the new principles, as practical business propositions, 
over the old ? 

The stumbling-block is that the general public still 
believes the teachings of twenty years ago concerning 
environment. These teachings were a mixture of the 
" old-wives fables " of the prebacterial age, with the 
early incongruities and half-truths of the new " theory " 
of bacteriology. 

Bacteriology is now an old-established science; but 
despite the fact that it has changed public-health work 
even more than it has changed medicine or surgery, — 
and both of these it has completely revolutionized, — the 
public still clings to the belief that public health is a 
curious profession, absorbedly interested in cutting 
weeds in vacant lots ("to prevent epidemics"), in 
burying dead animals and suppressing noisome odors 
(" to prevent epidemics ") ; in inspecting plumbing and 
collecting garbage ("to prevent epidemics"). The 
" good " health officer according to the popular stand- 
ard, still too prevalent, is he who keeps the streets clean 



INFECTIOUS DISEASES 21 

and the back alleys neat, who falls into a rapture over a 
newly whitewashed outhouse and into a rampage if a 
pile of old bones is found under the cellar steps. Yet 
many of those who know better let these ideas alone, or 
even acquiesce in them, " to save trouble." Neverthe- 
less it is expected that the thus carefully uneducated, 
or miseducated, public opinion will demand up-to-date 
action! Is it any wonder that the public insists on 
thinking, acting, and legislating to suit the theories of 
twenty years ago instead of the scientific knowledge of 
to-day ? 

Brief formulations of intricate principles are often 
misleading, incomplete, or fallacious; yet the tempta- 
tion to formulate the new principles briefly is strong, 
because their intelligent presentation to the public is so 
vital. Such formulation is attempted here. 

a. Sources of Infectious Diseases 

1. Infectious diseases are infectious because they are 
due to the growth, in the body, of minute animal or 
vegetable forms (germs), the transmissibility of these 
germs from body to body being the sole explanation why 
these diseases are " catching." 

2. Wherever in the body the germs develop, they 
leave it chiefly in the discharges, or by routes of the 
discharges, of the nose and throat, bladder, or bowel, 
i.e., from the main orifices of the body. 2 

2 This applies to all the ordinary infectious diseases in this 
zone. Smallpox, leprosy, syphilis, and some forms of tubercu- 



22 THE NEW PUBLIC HEALTH 

3. The discharges infect another person practically 
only when that person takes the discharges, in some 
form, into the mouth or nose, except in trachoma and 
the venereal diseases. 3 

4. Outside the body, disease germs do not multiply 
in nature, except perhaps rarely, and very temporarily, 
in milk, water, or similar fluids. In general, even 
typhoid bacilli disappear from water supplies within 
two weeks, without evident multiplication. If intro- 
duced into milk, most infectious-disease germs die out 
as the milk becomes acid, generally in a day or two. 
Infectious-disease germs are rarely found in garbage, 
and they quickly die out if deliberately added. Prac- 
tical modern public health recognizes therefore that the 
bulk of most of the infectious diseases are derived di- 
rectly, or almost directly, from infected persons, not 
much from infected things, except recently infected 
water, milk, food, and flies. The danger from the 
general environment of an infected person is therefore 
small. The things in his neighborhood need little con- 
sideration, except those very immediately about him 
and directly infected by his discharges, such as bed- 
clothes, personal clothes, towels, eating utensils, and 

losis are transferable from skin lesions at times. Certain tropi- 
cal diseases are transmitted by insects tapping the blood-stream, 
etc. Probably all infections can be conveyed, as anthrax and 
tetanus usually are, directly by inoculation. But these paths are 
so rare as to be negligible in ordinary life here. 

s " Infection is transmitted from an orifice of the infector to 
an orifice of the infectee." 



INFECTIOUS DISEASES 23 

other material objects that may receive, and retain for 
a time, fresh moist discharges. If attention be effi- 
ciently directed to infected persons and their discharges, 
the general surroundings may be safely ignored, except 
in the rarest instances. Disinfection of premises re- 
cently occupied by infectious persons (terminal disin- 
fection), a few years ago considered on theoretical 
grounds as one of the chief weapons against disease, 
has, on practical investigation been very largely aban- 
doned except in tuberculosis, where practical investiga- 
tion shows that it is of some value, if the premises are 
to be used within a month or so. 

b. Routes of Infectious Diseases 

5. The routes by which the discharges of the sick 
person pass to the well person are exactly those by 
which the same discharges pass from the well person 
to the well person in ordinary life ; for nose and mouth 
discharges the routes are mouth-spray, and sputum con- 
veyed through direct contact (as in kissing, etc.), and 
by the hands; for bowel and bladder discharges, the 
hands chiefly; and for all discharges, the things in- 
fected by them directly or through the hands, especially 
those things which then go to the mouth or touch things 
which go to the mouth, as food, water, eating utensils, 
towels, pipes, etc., etc. Flies also furnish an effective 
route, especially from feces to food. Water supplies 
are peculiar, because bowel and bladder discharges 
en masse, in the form of sewage, often enter them di- 



24 THE NEW PUBLIC HEALTH 

rectly, at times being deliberately poured into them 
from city sewers. 

6. The relative importance of these various routes 
in the carriage of infection varies much. The amount 
and freshness of the discharges, the number and viru- 
lence of the germs they contain, the size and frequency 
of the dose, and the number of susceptible persons who 
are dosed, must always be considered. Almost all the 
ordinary infectious-disease germs die out quickly on 
exposure to direct sunlight, and fairly rapidly in diffuse 
sunlight. When mucus, feces, and urine are thor- 
oughly dried on furniture, door-knobs, etc., they are 
not readily removed again without moisture and fric- 
tion, and when so removed the disease germs in them 
are likely to be dead or greatly reduced in recuperative 
power because of the drying. Hence, as a rule, things 
succeed in conveying infection only somewhat directly 
from the infector to the infectee, and practically only 
during the limited period when the germs are still fresh 
and moist. 

c. Control of Infectious Diseases 

7. These new principles place at the head of official 
public health activities, the search for and supervision 
of infected persons, and the control of the infected 
discharges, for the purpose of excluding them from 
mouths, and therefore also from food and drink. 
Prompt intelligent disinfection of all the excreta imme- 
diately after their discharge from the body (concurrent 



INFECTIOUS DISEASES 25 

disinfection), is the best weapon in the supervision of 
infected persons. Isolation of the infected person is 
the next best, and is more universally practicable, be- 
cause immediate intelligent disinfection of discharges 
can rarely be secured outside of the very best hospitals 
for contagious disease. The search for and supervision 
of mild, early, convalescing, unrecognized, and con- 
cealed cases and carriers, as well as of frank cases, is 
necessarily an essential item in the scheme. 

8. The modern public-health department requires ex- 
perts, but not experts in municipal house-keeping, in 
street-cleaning, garbage-disposal, smoke-prevention, etc. 
Its experts are the vital statistician, the epidemiologist, 
the laboratory man, and the sanitary engineer, the lat- 
ter dealing chiefly with the broad questions of water- 
supply and sewage-disposal. 



CHAPTER IV 
WHY DO ANYTHING? 

It has been well said that the day of the priest in 
public health has passed: to-day is the day of the doc- 
tor; but I think that to-morrow will be the day of the 
business man, the man of large affairs ; and it is to him 
this chapter is addressed. 

Until such time as poverty is abolished, or the State 
takes charge of children, the majority of the women of 
the race must continue to rear the majority of the chil- 
dren of the race inadequately, in homes too small, with- 
out facilities, doing for them somehow, individually 
and alone, that which three women could hardly do well, 
working together. 

This is not wholly a slum problem nor is it a problem 
of the rich. Numerically the race is chiefly middle 
class, neither rich nor extremely poor, judged by ordi- 
nary standards. This is the problem of the family 
with an income below $3,000, i.e., it is the problem of 
the race proper, and it is the old problem of the pre- 
mosaic Hebrew — how to make bricks without straw — 
alas, often without knowing how to make bricks at all ! 

The problem as a whole involves food, clothing, 

proper physical development, morals, education, amuse- 

26 



WHY DO ANYTHING? 27 

merit, discipline, and citizenship. But the public hy- 
gienist has as yet but indirect concern with these. The 
public hygienist — the " board of health man " — as yet 
concerns himself chiefly and by general expectation 
and consent, with the grosser, more imminent, more 
spectacular, more immediately tragic, problems of dis- 
ease and death, and chiefly with only one group of 
these, the infectious diseases. However much in ordi- 
nary life overcrowding, lack of facilities and overbur- 
dening of mothers may render unavailing even the tears 
and ageing, the back-ache, heart-ache, crooked fingers 
and wrinkled faces of mothers striving for their young, 
ten times over is the effect of these seen when disease 
enters the family, adding its burdens, its sorrows, its 
disabilities and its deaths. 

Once more, remember this is not in the slums alone, 
nor, numerically, chiefly there. It is found in city and 
country, village and town, everywhere, the overburden- 
ing of mothers, in ordinary life, added to ten times over 
when disease springs up. 

HOW BIG A PROBLEM IS IT? 

Call the population of the United States 100,000,000. 
Remember that, sooner or later, every member of each 
generation suffers from at least one-inieetious disease, 
often from two, three or four, and it is clear that every 
generation suffers anywhere from 100,000,000 to 300,- 
000,000 attacks of infections. Each generation pays 
out at least ten billions of dollars for this running of 



28 THE NEW PUBLIC HEALTH 

the gauntlet, not to speak of the disability and death of 
those who run it unsuccessfully. Tuberculosis, diph- 
theria, summer diarrhea, scarlet fever, measles, typhoid 
fever, whooping cough, chickenpox, to name only some 
of those best known to the laity, how much sorrow, dis- 
tress, poverty, how much " making of none avail " of 
mothers' hopes and prayers and wearing effort have 
these caused ! Yet so common are they that " children's 
diseases " are looked upon as a necessary stage, almost 
a joke. Indeed some people deliberately expose their 
children to them, " to have it over with " ! Yet who 
bears the burden, the sleepless nights, the extra work, 
the hope deferred ? 

Ninety-five per cent, of the infectious diseases are 
nursed at home by mothers. Next to the children them- 
selves the ones who suffer most are mothers. 



WHO KEEPS THE INFECTIOUS DISEASE GOING 



8 



Once more the answer is — and most emphatically — 
women in general, but chiefly after all the mother. To 
be sure there is every excuse for the mother, — over- 
work, overcrowding, lack of facilities, above all igno- 
rance and misdirected training, " misinformation piled 
on lack of any." But with all the perfectly good 
apologies stated and all the excellent good-will and ef- 
fort counted in, the fact itself remains, that mothers 
propagate and keep alive and spread the infectious dis- 
eases of children more than any other one body of peo- 
ple, and that while conditions remain as they are they 



WHY DO ANYTHING? 29 

must learn the " rules of the game " and follow them, 
for no amount of coaching or effort from the sidelines 
can do more than help. 

WHY AND HOW ARE WOMEN RESPONSIBLE? 

Because mothers are doing the work — women in 
general, but chiefly mothers. The farmer is responsible 
(apart from flood, drought, storm or other " acts of 
God ") for whatever happens to the crop from seed to 
market. Women in general — but chiefly mothers — 
are the " raisers " and " crop-handlers " of the largest, 
most valuable, most expensive and most difficult crop 
in the country. What happens to this crop between 
birth and sixteen years of age is, chiefly, what women 
do to it, or at least do not prevent. For the first 5,000 
days of the years of the life of each generation, the race 
is fed, dressed, undressed, washed, combed, cuddled, 
kissed, praised, blamed, led, driven, coaxed, taught, 
spanked, bossed and otherwise " brought up " by 
women — women mothers at home, women teachers at 
school. It is chiefly during this time of tutelage and 
supervision by women that children receive their infec- 
tions ; it is during this time that the race runs its gaunt- 
let, dances its little dance with death — and pays ten 
billions for it. 

PRESENT ATTEMPTS 

To teach women, girls, prospective mothers, that they 
may practice in their households, and in turn teach 



30 THE NEW PUBLIC HEALTH 

their children to war on invisible germ-foes is one of 
the functions of public health bacteriology. Only in 
the public schools can it be taught with emphasis, weight 
and uniformity enough to impress the masses. Only if 
taught in the grades can it be counted upon to reach 
the masses. Less than 1 per cent, of the population 
reach the university, only 10 per cent, reach the high 
schools. The great mass of the mothers of the coming 
generation, of the whole race, the mothers of more 
than their average of children, are receiving grade 
school education only. Need more be said % 

The infectious diseases in general radiate from and 
are kept going by women. Women must learn to break 
up, divert, stop in some manner — in every manner — 
the exchange of infected discharges amongst children at 
school and amidst families at home if infectious dis- 
eases are to be abolished or abated under present con- 
ditions. The needful information, beliefs, technique 
and habits cannot be had or established except by study- 
ing the basic principles of public health, and this must 
be taught in the grades of the public schools if it is to 
reach those who most need it. 

BADICAL CHANGES IN SOCIAL CONDITIONS THE EEAL 
SOLUTION 

If (as cannot be) every girl now at grade school could 
be thoroughly taught all that a trained nurse knows, 
theory and practice, the best to be hoped is that, be- 



WHY DO ANYTHING? 31 

coming a mother, ten to twenty years hence, she may 
remember enough to care for, if she have the facilities, 
the first case of infection in her household without per- 
mitting its spread to the other members or to outsiders. 
Alas, not one-third of the girls will remember, not one- 
tenth will have the facilities. Above all what shall be 
done in that intervening ten to twenty years ? Lectures, 
writings, sermons, appeals to mothers' clubs, university 
extensions, moving pictures, all the publicity that can 
be had or hoped for, will not suffice to teach technique 
to the mothers now in possession of the coming gener- 
ation. Nor once more, if it taught them, would it pro- 
vide the facilities needed. Economic conditions must 
change and change specifically to aid the mother if we 
are to gain at all. Also, the prevention of disease must 
engage the serious attention of governments — the pre- 
vention of disease, not the talking about it or the looking 
wise over it, or the making of fine addresses on it, but 
preventing it. Such prevention may include a tre- 
mendous organization to prevent human discharges en- 
tering water supplies, milk supplies, food supplies ; must 
involve watchfulness of hotels, restaurants, public insti- 
tutions of all sorts — in short, of all public alimentary 
utilities, with all their off-shoots and side issues wher- 
ever found. It must include, as its chief and most 
efficient weapon, the finding of the sources of infection, 
and the prevention of spread of infection from those 
sources. This is peculiarly a governmental function, 



32 THE NEW PUBLIC HEALTH 

but the whole must be cooperative. The government 
must strike at the sources and at the public routes of 
infection. The woman must strike at the private 
routes. The man must support both methods for the 
sake of the women and children. 



CHAPTER V 
NON-INFECTIOUS DISEASES 

SPECULATIONS 

The previous chapters indicated that so far as the 
infectious diseases are concerned, the great public- 
health fallacy of the nineteenth century consisted in the 
devotion of nearly all the effort to man's surroundings ; 
of almost none at all to man himself. We know now 
that the sources of infection are in man ; that the routes 
of infection are the routes of man's discharges ; and that 
the discharges are harmless until they enter man again. 
It is true that when the infective agents reach their goal 
the resistance of the individual, pitted against the in- 
jurious powers of the infective agents, decides whether 
or not actual disease develops. But this resistance of 
the individual is not to be measured by his surround- 
ings : it is intrinsic in himself. Alterations of intrinsic 
resistance do, of course, constantly occur, but the factors 
» of those alterations are not, as a rule, to be readily ascer- 
tained. We think that great extremes of malnutrition, 
temperature, and so forth may " depress " resistance. 
We have evidence that the smoke nuisance, poor venti- 
lation, or smells from slaughter-houses do not. In 

33 



34 THE NEW PUBLIC HEALTH 

brief, granted sufficient exposure to infectious disease, 
the susceptible individual will succumb, though he live 
in a palace ; the immune individual will escape, though 
he dwell in the slums. 1 

The immunity may be natural — born with the in- 
dividual — or acquired, but this is beside the question. 
Far more practically important is the fact that the im- 
munity, natural or acquired, is specific. The individ- 
ual may be wholly immune to one disease and ultra- 
susceptible to another; and such immunity has abso- 
lutely no relation to physique, robustness, or great 
vitality. 

The outcome of the environmental doctrines was the 
binding of heavy burdens of routine administration con- 
cerning surroundings upon health departments. Re- 
sults: garbage disposal, a polytechnic trade; street- 
cleaning, a scientific profession; plumbing, a fine art; 
and the supervision of infection, a dubious and usually 
a temporary " job," too often left to utter incompetents, 
or to those who, competent enough, are unable to de- 
vote any systematic energy and very little time to it. 

•We have pursued chimeras; pursued them in good 
faith of course, but chimeras none the less. 

Suppose now that we admit our errors and give to 

i Tuberculosis has long been held an exception to this rule. 
But tuberculosis was also held as (a) non- infectious and (b) 
hereditary, as well as (c) a result of certain surroundings. We 
have reversed (a) ; we have reversed (b) ; we already see good 
reasons to modify (c). 



NON-INFECTIOUS DISEASES 35 

the supervision of tuberculosis, 2 which we do under- 
stand, one-half the effort we have given to the super- 
vision of ventilation, which we are only beginning to 
understand. Suppose, in brief, we really organize and 
really operate a real machine which really does reduce, 
even promises to abolish, the infectious diseases. Will 
it be a surrender of our birthrights for a mess of pottage 
if in devoting ourselves to the suppression of disease at 
first hand, we forego the chasing down of loose paper 
on the streets and the cleaning up of rubbish piles on 
vacant lots ? 

PHYSICAL PEBFECTION 

There are activities contributing to health beyond 
these limits, of course; and some of them are things 
that should be done at once without waiting for the 
complete suppression of disease. For example, every 
one knows that the bodily welfare of mankind does not 
by any means hinge wholly on the infectious diseases. 
True, the abolition of these diseases means also the abo- 
lition of their immediate sequelae, — sometimes, as in 
measles, more harmful than the original attack, — and 
of their remote sequelae, the permanently injured kid- 
ney and the permanently weakened lung. But even so, 
a full half of our medical diseases and much more than 
half of our surgical diseases would still remain; more- 
over, merely to remove disease is not to solve the whole 

2 To say nothing of syphilis, gonorrhea, summer diarrhea, and 
the rest. 



36 THE NEW PUBLIC HEALTH 

problem of securing health in its true sense, i.e., the 
highest physical efficiency prolonged for the greatest 
period of time. 

THE GENERAL PROBLEM 

The chief of the many phases of disease and health 
are best shown by a parable : 

As a new automobile is accompanied by detailed in- 
structions for its care and operation, so the new small 
citizen should be accompanied by detailed instructions 
for his care and operation when he, a delicate and com- 
plicated machine, indeed, first appears on the scene. 
This knowledge is now accumulated by his parents 
chiefly from experience (which, remember, are his ex- 
periences) or by picking it up at random from the 
neighbors over the back-yard fence. To secure proper 
results, the instruction of the mother should precede 
the birth of the child ; and the proper care of the child 
involves proper care of the mother before the child is 
born. Prenatal and postnatal care are almost equally 
important to the child, and the former is peculiarly 
valuable to the mother. 

Again : As a new automobile is searched solicitously 
for missing or defective parts, to be solicitously and 
immediately made good before the machine is sent out 
to run against competitors on the highway, so the new 
small citizen should have at least his sight, his hearing, 
and his breathing tested before he begins the inevitable 
compulsory-education race against all comers on the pub- 



NON-INFECTIOUS DISEASES 37 

lie highway of the public schools. Pre-school supervi- 
sion will soon antedate school supervision. Why should 
the child suffer for its first five years defects and disa- 
bilities which are to be systematically corrected in the 
sixth ? But further : As the most initially perfect auto- 
mobile, most skillfully run, will yet, as time goes on, 
meet accidents, develop internal disruptions, and require 
repairs, so the new small citizen, despite early care and 
early correction of defects, will need supervision and 
repair all through his life, at school and afterwards. 

The parable must end here, for automobiles present 
no affections analogous to infectious diseases. This 
very fact, however, brings out more clearly the crucial 
distinction between man as a machine and man as a 
subject of infection. As a machine, he may be efficient 
or inefficient, well operated or ill operated, and this all 
quite apart from the existence of actual defect or disa- 
bility. Contrariwise, as a machine he may suffer initial 
defects or encounter accidents or develop internal dis- 
ruptions, all quite apart from his intrinsic efficiency or 
inefficiency and quite apart from the skill with which 
he is operated. But as a subject of infection, man is 
merely a soil more or less well suited to the growth of 
certain small plants, or animals. 3 

The most valuable production of the State is its citi- 

s The fact that in their growth these little invaders from with- 
out " mess up the works " and make trouble, as much as would 
disruptions originating wholly from within, should not conceal 
the radical difference between the sources and causes of defects, 



38 THE NEW PUBLIC HEALTH 

zens; and the State, properly conceived, exists only to 
insure life, liberty, and the pursuit of happiness to 
them. As the automobile maker insists, for his own 
sake, on (a) giving instructions and (b) correcting de- 
fects; so the State should, for its own sake, (a) instruct 
parents and (b) remedy children's defects, perhaps also 
the defects, disabilities, and diseases of adults. Cer- 
tainly, every State should provide at least — 

Education for parents in the personal hygiene of 
children, i.e., the care and operation of their children's 
bodies as machines ; and education also for children in 
the physical care of themselves. 

Supervision, not only for the mere detection, but also 
for the remedy, of initial defects; and should provide 
this early in life, the earlier the better, certainly not 
later than the beginning of the compulsory-education 
course. 

Supervision of children, at least throughout school- 
life, for the detection, and remedy, of such defects, disa- 
bilities, or diseases as may develop during that period. 4 

Finally, the supervision of infectious diseases. 

disabilities, and non-infectious diseases on the one hand, and of 
the infectious diseases on the other. The former may develop 
in any mechanism; the latter only in those mechanisms which 
furnish a suitable soil for the growth of the extraneous invaders. 
To prevent the former the machine must be well built and of 
the best stock, must be scrupulously watched for defects, must 
be constantly overhauled, and must be cared for and operated 
in the most skilful manner. To prevent the latter the mere 
exclusion of the invaders is all-sufficient. 

4 It is difficult to see strictly logical reasons why such super- 



NON-INFECTIOUS DISEASES 39 

THE PRESENT SITUATION 

But of all these manifold duties of the State to the 
citizen, only one of those which can be clearly shown 
to bear directly on his bodily welfare has been, as yet, 
fully recognized — only one rests on definite precedent, 
authorization and organization; and that one is the 
supervision of infectious diseases. The personal 
hygiene of the citizen (apart from the infectious dis- 
eases), and the remedy (even, until lately, the mere 
detection) of his defects, disabilities, or non-infec- 
tious diseases, have been regarded (except in the case 
of the pauper, the criminal, or the insane) as of little 
or no interest to any one but himself. And this, not- 
withstanding that all his material surroundings, and all 
his relationships, business and social, have been of ac- 
knowledged interest to the State from time immemorial. 
The sanitation of environment has indeed had much 
attention; usually misdirected and almost always in- 
efficient, so far as abolishing infections is concerned. 

Why this negligence of the individual, with excessive, 
misguided, attention to his surroundings? First, be- 
cause material surroundings are property, and property 
has always had precedence over persons in almost every 
relation; second, because, in the special relation to dis- 
ease, the old public health taught that the citizen was a 

vision should end with school-life. Germany and England are 
experimenting with the medical supervision of adults. Prenatal 
and postnatal supervision are already United States Federal 
projects. Minnesota is agitating pre-school supervision. 



40 THE NEW PUBLIC HEALTH 

resultant of his surroundings ; and even in the infectious 
diseases this fallacy ruled, as has been abundantly 
shown. 

Of course, the State is concerned with man's sur- 
roundings and relationships. It must consider, plan 
for, and carry out, measures for his comfort, conven- 
ience, safety, pleasure, and happiness, as well as merely 
for his health. The State exists to do for its citizens 
co-operatively, hence economically and authoritatively, 
all those necessary things which the individual could do 
only by great sacrifices or perhaps not at all. But to 
believe that the securing to the individual of every pos- 
sible advantage in all directions is the duty of the State, 
is not necessarily to believe that every item of this 
program should be carried out by health departments. 
To hand over to any one subdivision of the government 
control both of man and of his surroundings, would be 
to hand over to it all the functions of government. At 
once, subdivision of these activities would be necessary 
and these subdivisions would necessarily pattern after 
those of present governments. Hence such a " re- 
adjustment " would merely replace existing govern- 
ments, not add to their existing efficiency. 

The secret of successful organization is the parcelling 
out along natural lines of all the different activities 
which are to be co-ordinated to one great end. It is 
upon the shrewdness with which the subdivision into 
logical natural groups is done that the securing of 
smoothly-running co-ordination depends. Certainly, 



NON-INFECTIOUS DISEASES 41 

one most logical grand division of any government 
would be that which should deal with man apart from 
his surroundings; and one most logical subdivision of 
that unit should deal with his bodily welfare as distinct 
from his mental, moral, or other welfare. 

Using the automobile parable for guidance, such a 
" Commission on Bodily Welfare " should deal with — 

Item 1. The education of every citizen in personal 
hygiene. 

Item 2. The supervision of every citizen for detec- 
tion of defects, disabilities, and disease. 

Item 3. The treatment of every citizen for all de- 
fects, disabilities, and diseases detected. 

Item 4. Finally, that function to which the automo- 
bile analogy does not apply, i.e., the supervision of that 
small group of citizens, the infectious persons. 

How closely do we in America approximate this 
ideal ? 

Proper education of every citizen in personal hygiene 
{apart from the infectious diseases) is scarcely even 
foreshadowed by existing efforts. 

Medical supervision {apart from the pauper, the 
criminal, and the insane) is limited to a small portion 
only, of the school children only, in a few cities only; 
and does not pretend to remedy defects, but only to de- 
tect them. 5 

s About two-thirds of the children of America live and attend 
school in rural districts where medical supervision for defects 
is hardly yet more than contemplated. 



42 THE NEW PUBLIC HEALTH 

Treatment of disease {except for the pauper, the 
criminal, and the insane) is a matter of private pur- 
chase or of private philanthropy, usually the private 
philanthropy of the private practicing physician. 

The supervision of infectious persons is alone really 
established, authorized, or organized as a recognized 
duty of the State throughout America, and then only 
so far as the protection of others is concerned. We have 
not yet reached the treatment of the sick even though 
they be sick of infectious disease. 

But the mechanism for even the function of prevent- 
ing infection, although it is actually in existence, actu- 
ally organized, actually authorized, actually operating, 
and has behind it long years of legal precedence and 
the support of public opinion, is sadly under-manned, 
and under-equipped, — merely a skeleton. 

IMMEDIATE POSSIBILITIES 

It is true that even those advanced States which have 
organized, in part or in whole, the above outlined oper- 
ations, organized the control of infectious disease far 
earlier and more completely than they organized any of 
the others notwithstanding that that organization is 
usually inadequate in principle and inefficient in prac- 
tice. They have done so in accordance with a general 
rule, which governs all mankind, namely, that of doing 
first the simplest, crudest, and most obviously necessary 
thing. 



NON-INFECTIOUS DISEASES 43 

But it is also a matter of fact that the supervision of 
infectious persons differs essentially in principles, meth- 
ods, object, extent of application, and destiny, from edu- 
cation in personal hygiene, medical supervision for de- 
fects, or medical treatment. The latter are obviously, 
directly and immediately to and for the benefit of 
the individual who is educated, supervised, or treated. 
In principle, they are wise, fore-sighted and economic 
additions by the State to the welfare of its individual 
citizens. But the former is not to the benefit, usually 
rather to the temporary detriment, of the individual 
who comes under its operation. Its benefits are wholly 
to others, and even so do not add anything to their wel- 
fare, but merely prevent subtraction from it. 

The methods of the infectious-disease supervisor are 
necessarily those of the detective and the policeman, not 
those of the educator or the medical supervisor. The 
object he seeks is prevention, not construction or even 
repair. He does not deal equally with every citizen 
for that citizen's good, as does the educator or the phy- 
sician, but he ferrets out those few individuals who 
must be restrained for the good of the others. His des- 
tiny is, if successful, to eliminate the only reasons for 
his own official existence, while the educator and the 
medical supervisor will always continue to find in each 
new annual crop of children a new and constantly in- 
creasing field for their services. 

In brief, the first three activities are, like boards of 



44 THE NEW PUBLIC HEALTH 

public works, constructional in essence. Supervision of 
infection is, like the work of fire departments, conserva- 
tive merely. 

But although we may accept these four items as en- 
tirely proper for ultimate realization, we must acknowl- 
edge that the present public-health situation cannot be 
met merely by handing the outline over to boards of 
health or health departments as they exist to-day, not- 
withstanding that these departments constitute, by tra- 
dition and precedent, practice and organization, that 
arm of the government to which have been assigned the 
only activities of the State in relation to bodily welfare 
so far seriously or widely recognized. 

Health departments in general are under-manned, un- 
der-equipped, continually distracted with futilities like 
garbage collection, the smoke nuisance, abolition of un- 
necessary noise and other simple police matters of an 
administrative character. But if expanded, their dis- 
tractions eliminated, and their faces set sternly to the 
reduction of disease and death, they could not at once 
assume all the items of this program. Why ? 

The treatment of every citizen for all defects, disa- 
bilities and diseases we may dismiss from consideration 
at present. It is out of the question for some years to 
come in this country, despite the development reached 
in England. 

Eor the education of every citizen in personal hy- 
giene the basic necessities, — knowledge, authority, and 
organization, — are all lacking. Eor the supervision of 



NON-INFECTIOUS DISEASES 45 

every citizen for the detection (not the treatment) of 
defects, etc., knowledge, authority, and equipment can 
be had, it is true, although they may not be immediately 
available, but such detection of defects is closely bound 
up with treatment and should not be divorced from it, 
except as a method of demonstrating the need for treat- 
ment. 

Only for the supervision of infectious diseases have 
we now all three, — knowledge, authority and equip- 
ment, although the latter merely in outline. 

EDUCATION" 

Furthermore, it is true that the education of every 
citizen in personal hygiene, cannot be carried out prop- 
erly {apart from the prevention of certain diseases) by 
any organization at the present time. 

Why? Because such education requires, first, the 
knowledge, digestion, and formulation of the facts to be 
taught ; and, second, the training of those who are to do 
the teaching. 

But the best of us do not know personal hygiene 
{apart from the prevention of certain diseases) ; that is, 
we do not know how to care for and operate the human 
body as a machine. What, for instance, should be 
taught concerning diet when Chittenden and Wiley pro- 
mulgate exactly opposite views? What should be 
taught concerning ventilation when the whole subject 
is but just emerging from chaos? What should be 
taught concerning clothing, sleep, exercise, and fatigue ? 



46 THE NEW PUBLIC HEALTH 

Our physiologists study the normal body, but more 
in relation to disease than to health. Our vital statis- 
ticians seek the factors of morbidity, not of physical 
perfection. Even the famous Federal " poison squad " 
sought to determine what is bad for people to eat, not 
what is good for them. All of these things are, of 
course, useful, excellent, even essential to know; but 
they do not teach us personal health, they teach only 
the avoidance of actual disease. 

The truth is, that, as regards human bodily welfare, 
personal hygiene proper, we know, well enough to teach 
authoritatively, but one factor, that is the disease fac- 
tor. We know disease because we have studied it. We 
know, it is true, the " personal hygiene " of farm ani- 
mals because we have studied the " personal hygiene " 
of farm animals, at a cost of many million dollars a 
year. But we know nothing of the personal hygiene of 
human citizens, because we do not study the subject at 
all, except the hygiene of infants. We shall never know 
the personal hygiene of humans, apart, always, from the 
prevention of certain diseases, until we do study it — ■ 
until we put as much time, pains, and money into it as 
any agricultural experimental station in any State puts 
into the study of the " personal hygiene " of farm ani- 
mals. True it is a far more difficult subject, but that is 
the very reason why it requires immensely more study 
and experiment. 

We recognize that the study of animal hygiene re- 
quires care, trained investigators, years of experiment. 



NONINFECTIOUS DISEASES 47 

Why should we assume that the current dicta of those 
who pose as preachers of hygiene without study or spe- 
cial knowledge should be all sufficient in the case of 
the human ? 

There is, however, no real reason why health depart- 
ments should teach personal hygiene at all, apart from 
the prevention of disease, any more than that they 
should teach personal morals or personal finance. 
Health departments have no peculiar knowledge of the 
one any more than of the others ; and if they had, there 
are professional teachers much more competent and pos- 
sessing far greater facilities than any health depart- 
ment. 

Education concerning even infectious diseases is not 
strictly health-department work. This, like personal 
hygiene, should be taught seriously and systematically 
in the public schools. Ninety per cent, of the popula- 
tion never enter high schools, and only 1 per cent, 
reach the university. Whatever of personal hygiene or 
prevention of infection the citizen should know, must 
be taught in the grades or miss its mark. No amount 
of desultory pamphleteering or lecturing by health de- 
partments can ever take the place of properly conducted 
grade courses. Unlike courses in personal hygiene, 
about which we know next to nothing, courses in the 
prevention of infection could be established at once, 
since we know almost all about it ; but it is no part of 
health-department work to conduct such courses. 
Health departments are police bodies, not preachers or 



48 THE NEW PUBLIC HEALTH 

teachers. They may well, it is true, educate the edu- 
cators. There is no reason why they should educate 
the public, except the failure of the professional edu- 
cators to do so. 

MEDICAL SUPERVISION OF SCHOOLS 

Medical supervision of school children, so far as it 
deals with defects, deals with non-transmissible condi- 
tions. Medical supervision, so far as it deals with in- 
fection, deals with transmissible conditions. The latter 
therefore detects links in the chain of the ramifying 
threads of infection throughout the community, — a 
ramification, the threads of which unquestionably should 
be in health-department hands. 

But medical supervision for infectious disease in 
school as a means for general control of all infections 
has had a singularly exaggerated importance attached to 
it. Only one-half of the State's children attend school 
in any one year, and even the school child passes but 
one-ninth of each year in school. Were health depart- 
ments alert in their familiarity with, and efficient in 
their control of, the ramifications of the chains of in- 
fection outside of the schools, they would locate and 
supervise the infective child before, not after, he had 
infected school children ; before, not after, the medical 
supervisors for defects discovered him in the class-room. 
This would be accomplished incidentally to the control 
of infectious diseases amongst children below and above 
school age, as well as in adults. 



NON-INFECTIOUS DISEASES 49 

The fact is that medical supervision for defects need 
never encounter infection in that one-fourth of the total 
population which is contained in the schools, if health 
departments did their work properly in the other three- 
fourths which is outside of the schools. But this fact 
carries, alas, no guarantee that infective children will 
not, for a long time to come, occupy a share of the medi- 
cal school supervisors' attention because, for a long time 
to come, health departments will not effectively con- 
trol infection, inside or outside of schools, unless pres- 
ent methods are radically readjusted and expanded. 
Especially will this be true in rural districts where 
nearly two-thirds of the children secure their education 
and where health-department organization and equip- 
ment is, practically speaking, non-existent. 

Hence, whatever may be our individual views with 
regard to the ultimate relation of medical school-super- 
vision for defects to supervision of infectious persons, 
we need not blind ourselves to the fact that ideal condi- 
tions are far in the future, and that immediate necessi- 
ties call for immediate adjustments which may be tem- 
porary or not, depending on future developments. 

Medical supervision for defects and medical super- 
vision for infection are now, and for some time to come 
must remain, so interdependent that the closest co-oper- 
ation, even, in the rural districts, amalgamation, will be 
necessary. Such amalgamation should be under health 
departments, wherever that is possible, rather than 
under school boards. 



50 THE NEW PUBLIC HEALTH 

Eirst, because school boards have no authority through 
tradition, from precedence or by law, as have health de- 
partments to follow, outside of the schools, the ramifica- 
tions of infection of which the infective child in the 
school constitutes but one link, nor even to follow that 
one link back to its home. 

Second, because school boards have no information or 
authority concerning the full half of the children who 
are not of school age nor concerning any adult except 
those directly connected with the schools. 

Finally, amalgamation in the rural districts is essen- 
tial for one great reason, if for no other, and this reason 
is that if we do not combine both functions in one, in the 
rural districts, we shall not secure either function there 
at all. 

SUMMAEY 

Non-infectious diseases, disabilities, and defects con- 
stitute a field for governmental attention as great as or 
greater than do the infectious diseases. 

There are no theoretical reasons why governments 
should not concern themselves with the greater (the non- 
infectious group), as well as with the lesser (the infec- 
tious group). 

Public-health activities in their very broadest con- 
ception would include all the functions of government, 
since there is nothing of interest to man, from high 
finance to municipal playgrounds, which has not some 
relation to health. 



NON-INFECTIOUS DISEASES 51 

But an administrative system so vast as to control all 
human activities related to health would merely re- 
place the government, and would itself be necessarily 
subdivided, much as existing governments are now. 

It is not difficult to outline a logical program for one 
branch of any government, a branch which should deal 
with the bodily welfare of man and include hygienic 
education, medical supervision, medical treatment, and 
the suppression of infectious diseases. 

But there are many practical, as well as theoretical, 
reasons why health departments will not, indeed cannot, 
proceed at once to put this program into execution. 
Concerning education in personal hygiene, apart from 
the infectious diseases, agreement as to the basic facts 
to be taught has yet to be reached. As to the second 
and third items, organization, broad precedent, and 
broad authority are all lacking. 

Concerning the infectious diseases, and concerning 
them only, are the paths clear and the duties plain. 

The " instant need of things " is to do faithfully and 
well that one duty which we fully understand, the only 
one for which organization, authority, tradition, prece- 
dent, and the support of public opinion are already in 
our hands, i.e., the abolition of infectious diseases. To 
this end, the embryonic beginnings of the medical super- 
vision of every citizen — that is, medical school-super- 
vision — should lend its aid, especially in the rural dis- 
tricts. 

But until we have accomplished this — the simplest, 



52 THE NEW PUBLIC HEALTH 

easiest, crudest of our obvious and recognized duties, 
that one which lies right at our finger-tips — we cannot 
very well ask that the Nation should hand over to health 
departments all its great problems of life, death, health, 
and national development. 

To achieve the abolition of infection we must strip 
for action, discard all useless armor and antiquated 
weapons, cease desultory bombardment at leisurely long 
range of the enemy's outlying domains, and personally 
seek, with well-shortened weapons, the enemy himself 
(infection) in his real stronghold (the infective person). 



CHAPTEK VI 
EDUCATIONAL MECHANISM 

The teaching of these new principles of Public 
Health must begin with the teaching of the teachers. 
Until our leading public health men, physicians, physi- 
ologists, and clergy acknowledge these teachings and 
give them their endorsement the old misleading state- 
ments, household traditions, worn-out dicta, now consti- 
tuting the baseless platitudes of most public health be- 
liefs, will remain false beacon lights leading nowhere. 

It is time for all such leaders to awake and ask them- 
selves whence these teachings came. They are not in 
our books ; they are not propagated by our leading men 
of science. Eor instance no student of the subject has 
said a word to make any one believe that young children 
die of infections in less proportions than older children 
do, but quite the contrary. Yet in the face of all the 
books, all studies on the subject, all figures of statistics 
ever gathered, the medical profession itself in large pro- 
portions repeats the worn out sophistry : let them have it 
early and get it over — youth is the safest time; just 
as it repeats many another misconception not less ma- 
lignant in its evil leading. That typhoid fever is a filth 
disease and due to general dirt, has been exploded for 

53 



54 THE NEW PUBLIC HEALTH 

many years, yet we hear this statement made on every 
hand. Typhoid fever is not by any means carried by 
water only, yet this bit of knowledge seems still un- 
known to many leaders, even public health men. That 
the weak contract disease more than the strong one hears 
proclaimed from every pulpit, clerical or lay — but 
asked for their authority these proclaimers quote only 
the word of mouth of some physician who in turn can 
find only untraced tradition as his authority. 

Once leaders are agreed, the next most necessary step 
will be a revision of the teachings in Normal Schools ; 
and this necessitates the preparation of books on hygiene 
that will place in proper perspective all the real health 
measures that we have and show just what each one 
will do. The public must be trusted with the facts. 
The timid soul holds back the truth that bathing does 
not prevent disease, that lack of bathing does not end 
in sudden death, because forsooth he fears the children 
may come dirty to his school ! He forgets that the chil- 
dren often come dirty now, in spite of all his teaching ; 
true many others are clean, but both escape disease or 
suffer from it quite irrespective of the number of their 
baths. They who bathe from fear of death are few, 
and we must reach clean bodies by some other route 
than bogies held up with orotund words, bogies whose 
pumpkin heads and candle-sputtered light the listeners 
sense although they may not see the mechanism. Hon- 
esty in teaching is as necessary in our public health as 
in our mathematics or geography. 



EDUCATIONAL MECHANISM 55 

Let us face frankly this ; about the body-care we know 
few facts of practical application to our everyday life 
that are really hygienic, not merely aesthetic. We know 
of course we should not be, for high efficiency, too hot, 
too cold, too wet, too dry, too hungry or too full. We 
should not sleep too long, nor sleep too little, work too 
hard, or loaf, and so on ; but to say what is too much or 
too little for any given person, especially to lay down 
the golden mean, is something no one knows. The in- 
dividual variations in individuals are very great ; what 
is too hard work for one will scarcely stir the blood of 
another. " What is meat for one is another's poison." 
These variations are partly inherent; the exposure to 
cold which would be disastrous for the negro or even the 
white man is likely to suit the Inuit exactly; but also 
previous training and experience affect exercise and 
sleep and diet, etc., by the establishment of compensa- 
tions, for the range of adaptation of the body to vari- 
ations is very great: finally it seems probable that the 
following out of any exact " ideal " regimen would be 
in itself far from ideal, for it would do away with those 
very variations which, by cultivating compensations, 
maintain the body in its best state of general efficiency 
to meet the inevitable physiological emergencies of daily 
life. 

That such an ideal regimen would be far from ideal 
because of its utter impracticability for the great mass 
of the race seems seldom to occur to those who advocate 
the search for it. The great mass of the work-a-day 



56 THE NEW PUBLIC HEALTH 

world must now and for long generations yet to come 
eat, sleep, work, etc., not as they would but as they 
can. 

It is of course true that the excesses and the depriva- 
tions from which so many people suffer are so extreme 
as to be obviously harmful often even to themselves and 
quite obviously so to those acquainted with any sort of 
good bodily condition. But these extremes are often 
either results of poverty or, curiously enough, results of 
choice upon the part of those concerned, particularly in 
sleep, diet, and work. The race as a whole does not 
desire efficiency in practice, but chiefly excitement or 
amusement. To these ends, substituted in many minds 
for the more worthy pursuit of happiness, much of the 
lack of hygiene exemplified by the excesses and the 
deprivations may be traced, rather than to real neces- 
sity. 

The great preacher urging on his flock the highest 
ideals, often breaks down himself from over-strain, thus 
failing to practice what he preaches every day. The 
physician, the lawyer, the teacher, often neglectfully or 
deliberately break the simplest rules prescribing the 
most liberal limits for bodily success. 

Hence the educational campaign for hygiene, i.e., for 
bodily efficiency, must be antedated by or combined with 
a general reconstruction of ideals not based on mere 
intensity, but on all-round development ; and these must 
be so shaped that every one may have within his ready 
grasp the opportunities for such a life that the extremes 



EDUCATIONAL MECHANISM 57 

are not forced on him by circumstances taking their 
roots in the foundations of society itself. 

Hygiene then in its practical application to the world 
at large is something still far in the future, requiring 
as a rule the reconstruction of individual but far more 
of communal life. As yet we do not so study the body 
of the human in our physiology as to determine what 
are the ideal conditions. We are beginning to do so; 
and for our public institutions some sort of rules of 
thumb relating to clothing, exercise, and diet are traced 
out to meet the average wants. But who that knows our 
institutions would dare claim that the conduct of them 
really meets the bodily demands of all their inmates or 
brings them to the highest point of physical efficiency ? 
Too often, outside of armies, this is not by any means 
the ideal held in mind. In most institutions keeping 
down expense is the chief object ; in our industrial oper- 
ations the commercial output is the goal, not the condi- 
tion of the factory hands. True it is that public health, 
in the division which deals with hygiene (efficiency with 
comfort, and long life for all), must rest upon the at- 
tainment of the ideals sought by many sociological move- 
ments for the mental and moral recasting of the race. 
No movement which has for an object the proper under- 
standing of man or of any of his relations to the world 
can fail to be helpful in some way to this end. 

But when we turn to the second great item of public 
health, the prevention of disease, we find a different 
situation. True, as has been already explained, proper 



58 THE NEW PUBLIC HEALTH 

hygiene necessarily eliminates certain diseases which 
arise from improper living, accidents, the effects of 
monotonous repetitions of the same movements, or the 
monotonous maintenance of the same positions ; certain 
non-living poisons; and the internal disruptions and 
disabilities due to excesses and deprivations. The edu- 
cation needed to eliminate these must in itself be 
specific ; although the realization of their abolition must 
be the result of improvements in general social and 
trade conditions. Accidents occur amongst millionaires 
as well as amongst factory hands ; lead poisoning, phos- 
phorous poisoning, alcoholism, etc., depend after all 
upon taking those poisons into the body. They cannot 
occur under the worst sociological conditions, not even 
in the utter barbarism of the Central African village, 
unless those poisons enter into the system. The most 
important of all the preventable diseases, the infectious, 
are likewise due to specific poisons; but poisons alive, 
living and breeding in human bodies. No sociological 
advances, no moral developments, no improvement in 
living or in the relations of man to man, no raising of 
the standards of surroundings, no highest care of the 
body or attention to its efficiency can evade these unless 
the specific germ is evaded; which means evading the 
contact of uninfected man with infected man. But all 
sociological, moral and mental advance tend to cultivate 
contact, to bring all classes of people closer together, to 
knit the social fabric into more interdependent and 
mutually helpful structures. 



EDUCATIONAL MECHANISM 59 

Industrial advances gathering together larger and 
larger groups of people engaged in the same enterprises 
result in more and more social intercourse in masses, 
especially well knit if moral and mental development of 
the groups is sought. The public schools tend to more 
and more getting together, to wider interests, to the 
closer affiliation of each individual with every other. 
Improved transportation, the essential to national 
growth, has as its avowed object the extension of contact 
of one with another. The specific poisons of the spe- 
cific infectious diseases are transmitted by this contact. 
So long as such contact continues, much more as it is 
extended, these diseases will be more and more widely 
spread, unless the specific poisons themselves, which 
are bred in human bodies and transferred in human dis- 
charges, can be themselves eliminated. The hope that 
the remodeling of human conduct, the education of the 
race to protect each other by the elimination of the ex- 
change of these discharges, is negatived by the character 
of the exchange. True in the illicit venereal diseases 
the form of contact most often operative to propagate 
these diseases is a form of contact which is not essential 
to ordinary business or social relations and can be volun- 
tarily ended. But the moral and mental development 
of the race as a whole to the point where this form of 
contact is eliminated cannot be hoped for in many 
years to come. Like alcoholism, venereal diseases will 
be contracted so long as the specific cause is to be had. 
In the " children's diseases," each new crop of children, 



60 THE NEW PUBLIC HEALTH 

each theoretically amenable to training in self protec- 
tion, contract these diseases before they can be trained. 
Finally the technique of self protection and of protec- 
tion of others through the skillful limitation of the 
spread of discharges is a technique acquirable only 
after months of rigid training by those devoted to the 
especial studies and work connected with it, in con- 
tagious hospitals, so that even highly trained experts 
dealing with infections contract them at times; and 
when themselves infected find it immensely difficult to 
protect others unless they too are trained. Education 
directed to the vanquishment of these diseases must 
therefore be education pointing out the specific sources, 
the impossibility of the protection against them by any 
form of conduct practicable in ordinary life, and the 
necessity for the elimination of the infection itself. 
This elimination means the search for and the restric- 
tion of the small number of infected persons existing at 
any given time, with the object of eliminating infection 
from them and restoring them to the communal life 
when free of danger to the community. The mechan- 
isms needed to discover these infected persons, a general 
agreement that their temporary segregation is essential, 
a mutual helpfulness in discovering them and in assist- 
ing those charged with that duty, all these can be se- 
cured by education. But the actual doing of the work 
itself must rest in the hands of experts armed with 
full authority, pursuing their ends with quiet persist- 
ence and largely without spectacular show or noise. 



EDUCATIONAL MECHANISM 61 

To the extent to which the discovery and temporary 
segregation of the infected may remove these infected 
individuals from the communal life, such operations 
will benefit the communal life; and the provision for 
the care and maintenance of those thus segregated and 
of those dependant on them must be a communal 
charge. But the community would gain so immensely 
in efficiency and comfort and long life by the segrega- 
tion of the infected, because of the thus obtained elimi- 
nation of disease and death from the uninfected that 
the expense of suffering, disease, and death, existing 
now, might well be thus diverted to the purpose of es- 
caping both. 

SUMMABY 

The education of the public in personal hygiene, the 
development and efficiency of the body, must, like all 
other effective education, be carried out through the 
public schools; although immense service may be done 
by educational propaganda in the magazines and news- 
papers, which now form the postgraduate schools of the 
race. 

The elimination of those diseases which depend upon 
the physical surroundings must be a matter of specific 
training of those who come in contact with those spe- 
cific surroundings in such sociological improvements as 
may eliminate their existence. In the infectious dis- 
eases the poisons are not definite visible labeled things 
but, to the ordinary citizen, invisible and undetectable. 



62 THE NEW PUBLIC HEALTH 

They are not limited to certain kinds or forms of sur- 
roundings but exist in human beings themselves. They 
can be found only by specific methods and the condi- 
tions under which they are transmitted cannot be so 
sufficiently altered in practical everyday life as to re- 
strict their transmission by private effort. The infec- 
tious diseases therefore are peculiarly matters for di- 
rect Governmental control ; and the Governmental meas- 
ures undertaken must be planned and carried out, not 
merely to hold them in abeyance, but to secure their 
absolute abolition. 



CHAPTER VII 
THE OLD PRACTICE AND THE NEW 

EPIDEMIOLOGY 

The previous chapters were designed to clear the 
way for the constructive program which the following 
chapters seek to set forth. 

The conclusion so far reached is that the chief imme- 
diate duty of official public health is the abolition of all 
the infectious diseases. Eor this great enterprise, both 
scientific principles and scientific practice are essential. 
The new public health principles have been outlined; 
the new public health practice remains to be explained. 

Public health practice in handling infectious dis- 
eases may be traced through three distinct eras: past, 
present, and future. 

Past, or era of " general sanitation/' — The practice 
followed energetically in epidemics, spasmodically and 
perfunctorily at other times, consisted in a strenuous 
campaign of " general cleaning up " ; an orgy of sweep- 
ing, burning, scrubbing; an ecstasy of dirt-destruction, 
individual, household, municipal. 1 

i The reader is begged, pleaded with, besought, not to repeat at 
this point the wearisome old gibe — Then you want us to live 

63 



64 THE NEW PUBLIC HEALTH 

This " general sanitation " was a true old-style shot- 
gun prescription, used discriminately for any out- 
break of any disease. Ko distinction of sources from 
routes of infection was made ; indeed, that a distinction 
existed was hardly recognized, and, looking back, it 
sometimes seems that even the most obvious relations of 
cause and effect often were ignored. 

Present, or era of €€ specific sanitation/' — The best 
practice now is deliberately to analyze the particular 
outbreak of the particular disease concerned; speedily 
to determine thus the exact route of infection actually 
responsible ; and promptly to abolish or block that route. 

Future, or era of " supervision of sources/' — The 
practice, so far as it is possible to forecast it, will be the 
location and supervision of the sources of infection (in- 
fected persons) before, not after, they gain access to 
routes; thus in time eliminating infectious diseases en- 
tirely. 

like pigs? If not, why do you condemn "general sanitation"? 
We do not condemn " general sanitation," or cleanliness, or 
order, or decency. We simply present the scientific fact that 
these things do not greatly prevent, nor does their absence pro- 
duce, infectious diseases. They have a thousand advantages, but 
not this one. Honesty does not protect against lightning; yet 
this fact cannot prevent any truly honest man from remaining 
honest, nor does its statement in the least detract from the true 
virtues of honesty. And so with " general sanitation." It is 
specific, not " general," cleanliness that prevents infection. 
Specific cleanliness is that directed, not broadly and blindfold 
against all " dirt," but scientifically and efficiently against the 
one "dirt" (infected matter) that produces disease. 



THE OLD PRACTICE AND THE NEW 65 

It will be noted that public health practice as thus 
outlined, past, present, and future, forms a definitely 
developing mechanism, concentrating itself by degrees 
from the general to the particular, from the surround- 
ings to the individual, from (a) the random applica- 
tion of blanket measures, through (b) a specific detec- 
tion and a specific correction of a specific bad condi- 
tion, to (c) the actual forestalling of the development 
of such conditions at all. 

COMPAEATIVE METHODS 

To make clear this most important matter of public 
health practice, illustrations follow, exhibiting the pub- 
lic health practice of the different eras as each would 
operate in the face of a typhoid fever epidemic ; typhoid 
being selected because the control of this one disease 
alone calls for almost every modern public health prin- 
ciple, and, in some form, every modern public health 
practice. 

The end sought was, is, and always will be, the same, 
— to stop the spread of the disease. 

But the methods of the different eras contrast widely. 

In the past era of a general sanitation," a typhoid 
epidemic was met by a vigorous attack on dirt, damp 
cellars, dust, disorder; on garbage, manure, dead ani- 
mals, weeds, defective plumbing, and stagnant pools; 
cobwebs were cleared away; windows were opened to 
" let in the blessed sunshine " ; preachers preached 
cleanliness; teachers taught bathing; health officers 



66 THE NEW PUBLIC HEALTH 

limed back alleys and whitewashed outhouses. Human 
nature demanded " action/' and " action/' of a kind, 
was supplied. As a rule, the outbreak ran for weeks 
or months despite all that was done, exhausted the mate- 
rial available to feed it, and died out as any fire will 
if all the fuel is burned up. Whichever of the " meth- 
ods " for control happened to be instituted last re- 
ceived the credit of conquering the outbreak, although 
none of them had, as a rule, the slightest effect. 

We know now, what our forefathers did not know 
then, that typhoid infection is carried by water, food, 
flies, milk, and contact, and that " general cleaning up " 
could not remove infection from polluted water-mains, 
or purify a contaminated milk supply; could not stop 
the eating of infected food or eliminate contact infec- 
tion. 2 The only form of typhoid outbreak which " gen- 
eral sanitation" could at all affect was the form due 
to flies 3 carrying infected matter from accumulations 

2 Contact infection is the infection which radiates directly from 
the infected person through nose and mouth and bladder and 
bowel discharges. The hands of the infector and of his asso- 
ciates are the chief carriers of all these discharges, although 
mouth-spray and sputum also act in many diseases. Things 
directly infected by these discharges are also dangerous, but 
practically only while the discharges remain fresh and moist. 
The radius of action of contact is usually small; it compares 
with the radius of action of water, food, flies, and milk some- 
what as a bayonet compares with a machine gun in a general 
melee. But contact infection in the long run is more deadly 
than other routes, for there are many " bayonets " to each one 
such " machine gun." 

s We do not now use " general sanitation " even for fly out- 



THE OLD PEACTICE AND THE NEW 67 

of exposed bowel discharges, usually from non-fly proof 
toilets. In so far as the efforts at general sanitation 
may have had, at times, some remote and indirect effect 
on reducing the number of flies or separating them from 
the infected discharges, " general sanitation " may have 
at times had some partial and inadequate but still more 
or less helpful results. But of course the fly was not 
then known as a route of infection in typhoid, so that 
even the results that " general sanitation " secured were 
secured largely by accident, i.e., by the unrecognized 
conjunction of an unappreciated remedy with an unde- 
termined cause. 

The present era of " specific sanitation " began a dec- 
ade or so ago. Water, food, flies, and milk have grad- 
ually become fully recognized as the main public routes 
of typhoid infection, i.e., as the main routes from indi- 
vidual to group, and from group to group; contact, es- 
pecially of late, has been recognized as the great private 
route, i.e., from individual to individual. Outbreaks 
have been met chiefly by finding the particular route 
involved, and by abolishing or blocking that route. 
But even in this era, the earlier practice for the attain- 
ment of this end differed fundamentally from that of 
to-day. 

breaks. From this old shot-gun prescription we have eliminated 
all the ingredients but one, that one which alone was active. 
In fly outbreaks we exclude flies from infected discharges, and 
(so far as the primary outbreak is concerned) then stop. So 
does the outbreak. 



68 THE NEW PUBLIC HEALTH 

The earlier epidemiologists 4 of this era argued thus : 
" Water, food, flies, and milk are the known public 
routes; usually some one of these routes is responsible 
in each outbreak. Therefore, to find the responsible 
route in any given instance, flood the stricken commu- 
nity with trained inspectors; analyze the water sup- 
plies; investigate the milk supplies; go through the 
markets; delve into the provision stores; estimate the 
number of flies, and locate their breeding-places; sur- 
vey the back alleys and out-door toilets ; plat all results 
on maps ; interview the city engineer, the fire marshal, 
the meat and milk inspectors, and examine their official 
records ; secure the morbidity and mortality records of 
the board of health ; study all available meteorological, 
topographical, geological, and other data; in brief, 
probe, dissect, tabulate, collate, and compare all pos- 
sible physical information concerning the co mmu nity. 
Under such inquisition the guilty route of infection 
can scarcely escape detection/' 

For these methods it must be said that they were 
scientific, logical, and exhaustive; but they were ter- 
ribly laborious and generally exceedingly slow. Of 
course it sometimes happened that the guilty route of 
infection was stumbled on at once; and almost always 
this end was reached sooner or later, too often, how- 
ever, only after weeks, months, or even years of effort. 
The ponderous slowness of these methods took them 
out of the class of effective emergency measures, and 

* Experts on epidemics. 



THE OLD PRACTICE AXD THE NEW 09 

this was recognized even then, for a typhoid investiga- 
tion was not then considered a matter of haste, in initi- 
ation or in execution. 

These earlier methods parallel somewhat those which 
we might suppose an amateur hunter to use, if he were 
commissioned to find a certain sheep-killing wolf. 
Confronted with this problem, the amateur might, not 
unreasonably, flood the surrounding mountains with 
assistants, instructing them to find all the existing wolf- 
trails, and to follow each such trail inward towards the 
slaughtered sheep until satisfied that it did, or did not, 
actually lead to them. 

The methods of to-day are the exact converse of 
these. Instead of finding in the mountains and fol- 
lowing inward from them, say, 500 different wolf trails, 
499 of which must necessarily be wrong, the experi- 
enced hunter goes directly to the slaughtered sheep, 
finding there and following outward thence the only 
right trail, — the only trail that is there, — the one 
trail that is necessarily and inevitably the trail of the 
one actually guilty wolf. 

THE XEW EMERGENCY EPIDEMIOLOGY 

The epidemiologist of to-day, called to a typhoid- 
stricken community, at first pays no attention at all to 
the physical condition of the existing possible routes. 
It is sociological data, not physical, that he needs at 
this stage. He knows that, counting the wells, the 
toilets, the milk supplies, etc., there may be 500 of 



70 THE NEW PUBLIC HEALTH 

these possible routes; but he does not go to see them, 
nor even the pumping-station or the sewage-outfall. 
He goes, hot foot, straight to the " slaughtered sheep " 
— straight to the patient's bedside. There, and there 
only, can he expect to find the trail of the guilty wolf — 
the route by which the infection reached that patient. 
There, in thirty minutes, he reduces the 500 possibili- 
ties to, say, 10, i.e., to those encountered (a) by this 
patient 5 (b) at a certain time (the date of his infec-* 
tion). These 10 are carefully listed; but the epidemi- 
ologist does not investigate even these 10. He goes, 
instead, straight to another bedside and lists there the, 
say, 10 routes that constitute the possible routes for 
this second patient; but he does not investigate the 
routes on this list either; he merely compares the two 
lists. Why? Because the one guilty route quite evi- 
dently must be on both lists. Thus if both lists show 
the same water supply, that water supply remains a 
possible guilty route; but, if not, water is eliminated. 
If both lists show the same milk supply, that milk sup- 
ply remains a possible guilty route ; but, if not, milk is 
eliminated. Discarding thus the routes not common 
to both lists, 5 routes, say, still remain. At the third 
patient's bedside these 5 are reduced by similar treat- 
ment, to say, 3. So the search goes on until the epi- 
demiologist either locates the one main public route 

s Of course imported and secondary cases are not used for this 
purpose, and at this stage the epidemiologist is most careful to 
eliminate all such from his tabulations. 



THE OLD PEACTICE AND THE NEW 71 

common to all or proves that the outbreak is not due to 
such a public route at all, but to the private routes ex- 
tending directly from person to person, i.e., to contact. 
Often in twelve hours of such work, generally in twen- 
ty-four, almost always in thirty-six, the evidence is 
conclusive. The guilty route stands out convicted ; for 
it is found on every list, and the innocent routes are 
exonerated, for they occur only on some. 6 

STOPPING A " PEIMABY " EPIDEMIC 

Now, at last, and not till now, does the epidemiologist 
deal directly, with the route of infection thus indicated, 
examine it to find just how it is responsible, including 
the source of its infection, and thus provide the initial 
data for its remedy. 7 These remedies consist broadly 

« Obviously this method fails if there be but one patient, for 
then comparison of lists is of course impossible; but single 
cases usually prove to be imported or from contact. Also it may 
happen that even three or four patients do not furnish suffi- 
cient data to narrow the possible routes to one; obviously, the 
more patients there are the more conclusive the results. But 
even when only a few patients exist, this method reduces the 
number of routes to be investigated to say, 10, often to 2 or 
3, an immense reduction from the original 500. 

7 To those who are not familiar with modern public health 
work, this account may seem incredible or at least exaggerated, 
yet these are the regular procedures of emergency epidemiology 
wherever they are understood to-day. Records of such work 
in America for years back are open to all enquirers. More- 
over, the above account has pictured the epidemiologist work- 
ing under a most disadvantageous condition, i.e., in complete 
ignorance of the community he deals with, except for what 
he learns during the investigation itself, If previous familiarity 



72 THE NEW PUBLIC HEALTH 

in one of two general procedures — the prevention of 
further infection of the guilty route — or, if this can- 
not be accomplished, the installation of some method of 
removing the infection after it has been unavoidably 
admitted. The former method is " the abolition of 
the source/' the latter " the blocking of the route," 
As illustrations of the former may be cited the diver- 
sion of an infected feeder from an otherwise pure 
water supply; the disinfection of the discharges of 
typhoid patients before deposit in outdoor toilets; the 
elimination from a milk-business of a typhoid-carrying 
employee; in brief, the prevention of infection of the 
public routes by elimination of the sources of infection, 
which are typhoid-infected discharges. As examples 
of the blocking of routes may be cited the boiling, the 
chemical disinfection, or the filtration of a polluted 
water supply; the pasteurization of infected milk; the 
disinfection of the hands of those who are typhoid-car- 
riers or who handle the typhoid-infected discharges of 
others. 

The simplicity, effectiveness, and inexpensiveness of 
the abolition of sources as compared with the blocking 
of routes is evident on a moment's consideration. Yet 

with the affected conmiunity exists, the main public route of 
infection can often be determined without leaving headquarters, 
provided merely that correct data as to the number, location, 
and dates of infection of the cases are submitted. Of course 
such " long-distance epidemiology," wonderfully accurate though 
it can be made, does not compare in reliability or in finish of 
detail with actual personal investigation on the ground. 



THE OLD PEACTICE AND THE NEW 73 

in the slow development of human knowledge and ap- 
preciation of their relative values, the latter are still 
relied upon as a rule almost to the exclusion of the 
former. 

It is at the point when the guilty public route is 
shown (if public route there be) that the epidemi- 
ologist, so far as this public route is concerned, steps 
out, and the bacteriologist, the chemist, the sanitary 
engineer step in; one, or any two, or all three, as con- 
ditions may require. It is they who at the present 
time and as a rule must work out the most available 
methods of (a) immediately ending present danger; (b) 
permanently providing against its recurrence. 



But detecting and demonstrating the guilt of a main 
public route, when such is involved, by no means ends 
the epidemiologist's duties. The work outlined so far 
is required (in America) chiefly in typhoid out- 
breaks; and then chiefly in those typhoid outbreaks 
which are derived from water, food, flies, or milk. 
The work still to be done is required in all typhoid 
outbreaks, whether initially derived from these public 
routes or from contact ; moreover, it is called for in the 
majority of outbreaks of all the other infectious dis- 
eases, because the majority are usually contact out- 
breaks at all stages. That work is the prevention of 
further spread by contact. 

To understand this clearly, it must be remembered 



74 THE NEW PUBLIC HEALTH 

that under present conditions every typhoid, or other, 
epidemic which begins from some one public route 
(water, food, flies, or milk) soon presents two distinct 
parts; the primary outbreak, consisting of that group 
of persons who received their infection wholesale 
through the public route; and the secondary outbreak, 
consisting of those individuals who later, by the private 
routes of contact, receive their infection individually 
and directly from the individuals of the primary set. 
Those typhoid, or other, epidemics which begin through 
the private routes of contact, i.e., when one infected 
individual succeeds in directly infecting a large group, 
do not, of course, present a " primary " outbreak at all. 
They are, so to put it, " secondary " outbreaks from the 
outset. (Of course, it will be understood that these dis- 
tinctions are somewhat artificial and for convenience. 
The so-called primary outbreak affecting wholesale a 
group of persons through a public route of infection 
such as a public water supply, milk, etc., does not truly 
originate with the water, milk, etc., which is involved. 
A previous case or group of cases must of course have 
infected the water or milk. Typhoid fever is not gen- 
erated by these or any other routes; they act merely as 
transmitters from person or persons to person or per- 
sons. The chain of infection therefore reaches back 
into the past indefinitely to the hypothetical day, in- 
definite ages gone, when the typhoid germ first ap- 
peared upon the stage of the world's history.) 

The search for a public route is therefore only the 



THE OLD PEACTICE AND THE NEW 75 

first step in subduing any epidemic. If such route 
exist, this step, by finding it, provides for getting rid 
of it, which prevents the infection of any more persons 
from that route, and so ends the primary outbreak. 
But this first step by no means ends the epidemic as a 
whole, for the persons already infected from that pub- 
lic route constitute each one a source of further spread 
by contact, a spread which, of course, must also be 
prevented. Obviously, epidemics which are contact 
epidemics throughout, necessarily present an identical 
problem from this standpoint, for every existing in- 
fected person, whatever the route of his infection, is a 
separate danger, and each requires supervision. 8 

FINDING THE UNKNOWN CASES 

How does the prevention of further spread by contact 
infection from existing cases depend on epidemiology? 
Cannot the spread of infection by contact from existing 

s In earlier days the fallacy that typhoid fever patients could 
not directly infect their associates — in brief, that typhoid fever 
was not contagious — was responsible for the long-delayed recog- 
nition of secondary typhoid outbreaks, even after the origin of 
primary outbreaks had been learned and methods of dealing 
with them perfected. We know now that abolishing or blocking 
a primary route is but half the story. The primary cases, if 
neglected, may continue to infect other persons by contact, and 
these again others, ad infinitum. Such secondary outbreaks may 
extend slowly for months or years and yield cases equaling or 
exceeding in number those from the primary outbreak. The 
" endemic typhoid " of some localities is at times an unrecog- 
nized, slow-moving, secondary outbreak. 



76 THE NEW PUBLIC HEALTH 

cases be guarded against by the attendants (nurses and 
physicians) which each such case (if known) necessarily 
has ? True, and were these known cases the only dan- 
ger-points, proper attention to preventing spread from 
them would be all-sufficient. But the known cases usu- 
ally form but half of the danger-points because only 
half of the dangerously infected persons become known 
cases. The other half consists of " missed cases " 
(mild, unrecognized, and concealed cases, early cases, 
and, later on, convalescing cases) and of " carriers." 
(The " carriers" are infected persons, capable of in- 
fecting others, but not themselves made ill by the dis- 
ease germs which they nevertheless carry and distrib- 
ute.) 

Missed cases and carriers, unless especially sought 
for, are, and must necessarily remain, unknown to those 
capable of guarding them ; they have no known attend- 
ants to whom the prevention of spread of infection 
from them can be entrusted; they generally do not 
know themselves to be infected; and, if ignored, they 
are more dangerous, because inevitably unguarded, than 
the known cases, for, being known, the latter can be 
guarded. 

This problem, the finding of missed cases and car- 
riers, is now solved by an epidemiological procedure 
which, while less spectacular, is far more widely useful 
than that of finding public routes, because it applies, 
not alone to contact-typhoid outbreaks, but to all con- 
tact outbreaks, that is, to all infectious diseases, from 



THE OLD PEACTICE AND THE NEW 77 

tuberculosis down. Were the ability to find public 
routes of infection in water, food, fly, and milk out- 
breaks the only virtue of epidemiology, its services, im- 
mense though they have been to the control of primary 
typhoid, could have no value in the great mass of infec- 
tious disease, for the great mass arises chiefly by con- 
tact. It is the ability to find the private sources of in- 
fection in contact outbreaks that makes epidemiology 
the pivotal factor of modern public health. 

This location of missed cases and carriers in typhoid, 
and other, outbreaks, is called concurrent epidemiology, 
and is well worth thoroughly understanding. Its ex- 
planation will be found in the next chapter. 

SUMMAEY 

Modern public-health practice for the control of in- 
fectious diseases consists, not in the physical surveil- 
lance of whole communities, but in the sociological 
study of the infected persons in them. 

This practice is best illustrated in the modern han- 
dling of typhoid fever epidemics, because this disease 
is all-inclusive, i.e., it travels by all four of the great 
public routes (water, food, flies, and milk), as well as 
by the private fifth route, contact ; also because typhoid 
is an intestinal infection and, of all the infectious dis- 
eases of the temperate zone, the intestinal infections 
alone travel by all of these five great routes. 

A typhoid epidemic is approached, as is any other 
epidemic, first, to determine if any public route of in- 



78 THE NEW PUBLIC HEALTH 

fection is involved, and, if so, what that route is and 
how it operates, including often how it became infected 
in the first place; thus finding how to stop further 
infection of groups of people through it; second, to 
determine the private routes and sources of the contact 
outbreak from individual to individual which, sooner 
or later, develops in all epidemics, whether the orig- 
inal route be a public route or not. 

To the epidemiologist, the public-health detective, 
falls all these crucial tasks. It is his function to find 
those underlying facts concerning the sources and 
routes of infection which alone can form a sound basis 
for real remedial measures. 

How he performs the finding of public routes and 
often, of the sources of their infection, has been de- 
scribed; the finding of private routes and sources will 
be described later. In both procedures the initial step 
is the same, namely, the investigation of the known 
cases. By seeing and questioning hnown cases, or their 
immediate relatives and attendants, the epidemiologist 
can classify them into native and imported. The na- 
tive cases, since they alone originated in the community 
under investigation, are further classified into primary 
and secondary cases. From the histories of the pri- 
mary cases, if such there be, he learns the public route 
and provides thus the data for its abrogation. From 
all the cases, imported, primary, and secondary, he ob- 
tains the data needed for the next step. 



CHAPTER VIII 
THE NEWEST PRACTICE 

COJSTCUKRENT EPIDEMIOLOGY * 

The preceding chapter outlined the first step in the modern 
handling of a typhoid fever epidemic, typhoid fever being 
selected because its proper handling illustrates best the prin- 
ciples and practice of modern public health work. 

The first step is the discovery, by the methods of emergency 
epidemiology, whether water, food, flies, milk, or contact 

i Emergency epidemiology is the epidemiology required in out- 
breaks from single great routes — water, food, flies, milk. Con- 
current epidemiology is the epidemiology required in contact 
outbreaks, i.e., outbreaks from multiple private sources. Emer- 
gency epidemiology is rapid and spectacular; it is played hard, 
against time, to save large groups of people. Concurrent epi- 
demiology is relatively slow and plodding; it ferrets out, one by 
one, the individual persons whose infection threatens families 
or small groups. Emergency epidemiology will disappear when 
the great routes are properly protected by purification methods 
or, even better, by such supervision of all cases that infection 
of such routes becomes impossible. Concurrent epidemiology 
will greatly develop; it is the most powerful and practical 
weapon yet devised for the abolition of the infectious diseases 
and hence for doing away with the necessity of guarding routes 
at all. To revert to the wolf parable, guarding the routes by 
which the wolves may reach the sheep is good, provided eternal 
vigilance and a uniformly high standard of efficiency are main- 
tained. Abolition of the wolves themselves is far more con- 
clusive, and would make unnecessary the burden of guarding the 
routes for all time. 

79 



80 THE NEW PUBLIC HEALTH 

bo the original main route of infection. The second step, 
to be outlined in these pages, is the location, by the methods 
of concurrent epidemiology, of all the infected persons 
(known cases, missed cases, and carriers). These are located 
because each, regardless of the original route by which he 
himself became infected, forms a new center of infection for 
spread by contact which will continue the outbreak in- 
definitely until such transfer is stopped, accidentally, or by 
exhaustion of susceptible material. 

It was further pointed out that neither emergency epi- 
demiology nor concurrent epidemiology were limited in 
their application to typhoid fever; and that the ability of 
concurrent epidemiology to handle properly contact typhoid 
outbreaks, whether contact be the secondary or primary 
route, is a conclusive demonstration of its ability to handle 
all other infectious diseases, since these others, while spread 
by public routes to some extent, are, in the mass, contact 
infections chiefly. No dependence on the argument by 
analogy from typhoid fever to other diseases is needed, how- 
ever; for these other diseases are now and have been for 
years past handled successfully by these very methods. 

Most persons contemplating the problem of finding 
missed cases and carriers for the first time, pronounce 
it impossible; then suggest, as the only solution, a 
house-to-house canvass of the whole community, hastily 
adding that of course such a measure is quite imprac- 
tical. As a matter of fact, the public health detective 
does at times use, and use successfully, exactly that 
" impractical " measure, — the house-to-house canvass. 
This house-to-house method is used in primary out- 
breaks from public routes, to locate unreported primary 
" known cases/' and also to locate primary missed cases 



THE NEWEST PEACTICE 81 

and carriers. It is necessary in such primary out- 
breaks because the distribution of primary missed cases 
and carriers, as well as of " known cases/' is co-exten- 
sive with that of the guilty route. There is no other 
guide to their location, and therefore the whole distri- 
bution of the guilty route must be searched. But the 
need of such a canvass of a whole community seldom 
arises except in typhoid or other infectious intestinal 
outbreaks; and then only when the infection is spread 
by a route common to the whole community ; and there- 
fore practically only when the guilty route is a public 
water supply. In milk outbreaks, those who did not 
use the guilty milk need not be examined ; and a similar 
statement is true also regarding food outbreaks. Fly 
outbreaks rarely affect a whole community unless the 
community be very small ; and in small communities of 
course a general canvass is not difficult. 

In the majority of epidemics, and because the major- 
ity of epidemics are due, not to great public routes, but 
to private contact, the finding of missed cases and car- 
riers does not require even a partial house-to-house can- 
vass. This is true of secondary typhoid, and other 
secondary outbreaks (which are contact outbreaks) as 
well as of the great majority of all outbreaks (since the 
majority are contact outbreaks only). 

The reason why missed cases and carriers can be 
found in contact outbreaks without a house-to-house 
canvass depends upon a fact of which the true signifi- 
cance is not fully appreciated outside of epidemiologi- 



82 THE NEW PUBLIC HEALTH 

cal circles. It is this: such missed cases and carriers 
are not distributed at pure, blind random anywhere and 
everywhere throughout the community. They occur in 
certain groups — and these groups can he located be- 
cause they betray themselves through their connection 
with known cases. Hence the location of known cases 
locates these groups also. 2 

This most important epidemiological principle is 
called the principle of zones of infection. It is the car- 
dinal principle of concurrent epidemiology. 

The principle of zones of infection was first clearly 
recognized in diphtheria epidemics, and its develop- 
ment and demonstration as a practical working rule de- 
pends, primarily, on diphtheria investigations ; 3 but 
both principle and practice have now been established 
for all the well-studied epidemic diseases. 

The epidemiologist, 4 in putting this principle into 
practice, locates first the known cases, and then searches 

2 It must not be supposed that these groups are confined to 
families, immediate neighbors, etc. Their true basis is socio- 
logical relationship, not mere physical propinquity. In a single 
scarlet fever outbreak originating in one community Dr. A. J. 
Chesley found the related sociological groups distributed in 3 
States, involving 3 cities, 2 villages, and 24 townships in 10 
counties. The Mankato typhoid fever outbreak of 1908 affected 
over 40 points outside of Mankato. 

3 Developed largely by Drs. F. F. Wesbrook, L. B. Wilson, and 
0. McDaniel in Minnesota. 

4 It must be evident that those private practising physicians 
who are not health officers, cannot, for many reasons well under- 
stood by the profession, do epidemiological work, emergency or 
concurrent, except in overwhelming outbreaks, where ordinary 



THE NEWEST PEACTICE 83 

the zones of infection, which they indicate, for missed 
cases and carriers. The methods of this search vary 
with each disease and are described in some detail in 
other chapters. Detective methods are used, illumi- 
nated by expert technical knowledge of each disease, 
its natural history, and the means, laboratory and 
clinical, of recognizing it, at every stage a;nd under all 
disguises. Suffice it to say now that the finding of 
missed cases and carriers, as well as of known cases, — 
that is, of the very framework of the ramifying threads 
of the infectious disease, — is a problem not only solv- 
able, but already solved, and already reduced to a 
routine basis. As an art, this concurrent epidemiology 
is somewhat more arduous and time-consuming than 
the art of emergency epidemiology, but it is thoroughly 

conventions and social relations are temporarily foregone. Even 
those private practicing physicians who are also health officers, 
encounter difficulties and obstructions, ethical, social and con- 
ventional, which professional epidemiologists, who are not in 
private practice, do not meet. Hence in all outbreaks the physi- 
cian finds that his most valuable functions consist in treating 
the sick and in advising protective measures to those who apply 
to him. Physicians also often combine, very successfully, to 
publish material or give public lectures of instructions during 
epidemics. But, after all, the chief service which the physician 
can render to official public health is the reporting of known 
oases. Known cases, as has been shown, are the basic datum- 
points for emergency epidemiology, i.e., for the finding of the 
routes of infection; and they are even still more important to 
concurrent epidemiology, i.e., in the study of the zones of infec- 
tion. Epidemiology is greatly aided when the physician per- 
forms thoroughly this, his primary, public health duty. 



84 THE NEW PUBLIC HEALTH 

practical and has been successfully followed for years 
past all over Minnesota, in an average of four to six 
epidemics every week. 5 The visiting nurse in " con- 
current epidemiology," can be made a most valuable 
and efficient aid, to say nothing at present of the other 
and even more indispensable services in other direc- 
tions which are within her especial province. 

This principle of zones of infection applies to tuber- 
culosis just as to any other infection spread by contact ; 
indeed, the location of missed cases in tuberculosis 
(carriers in tuberculosis are hypothetical to date) offers 
less difficulty to modern epidemiology than the same 
problem in other infectious diseases. 

FUTUEEI APPLICATIONS 

So much for past and present practice. 

Turning now to the future era of " supervision of 
sources," the principles and practice already described 
pave the way for appreciation of the probable develop- 
ments. In reconsidering the wolf metaphor already 
outlined, every one will ask, and wisely, Why wait until 
some sheep are killed before we protect the others? 
Why not patrol the known routes by which the wolves 
reach the sheep; or, better, build wolf -proof folds; or, 
best of all, teach the sheep to protect themselves — to 
fight the wolves or at least to dodge them ? 

Those who believe that infectious disease can be 

s See reports of the Minnesota State Board of Health for 1911 
and 1913. 



THE NEWEST PKACTICE 85 

warded off, in the face of infection, by diet, 6 exercise, 
good ventilation, and " strict observance of the laws of 
bodily health/' are those who would train the sheep to 
fight ; would train the body to destroy all infection that 

6 A most important exception to the general statement that 
proper diet in itself cannot prevent the development of infection 
provided infection gains access to the body should be recorded to 
cover the case of nursing infants. It has long been noted that 
breast-fed infants, during the period that they are so fed (but 
during that period only) are, practically speaking, immune to 
many infectious diseases. This is so true of scarlet fever and 
measles, that in such diseases no great concern need be felt 
for such an infant, even though the mother herself have the 
disease. In diphtheria, a nursling to some extent shows a like 
immunity. In smallpox, this is not true and in tuberculosis it 
is at most very doubtful. 

That this escape of nurslings is purely a matter of the enor- 
mous advantages in nutritional value, to an infant, of mother's 
milk over other foods has yet to be demonstrated. Nursing 
infants are by the mere fact of nursing less likely than are other 
infants to be exposed to whatever routes or sources of infection 
may be about, unless the mother is herself a source. But in 
scarlet fever and measles, at least, this is not the whole ex- 
planation. It has been suggested that the real reason lies in 
the transmission to the child of actual immunity-producing bodies 
in mother's milk. If this be so, breast-feeding in infants as a 
protection against certain infectious diseases combines in one 
operation three principles of defense; good nutrition, specific 
immunization and the avoidance of infection. Other forms of 
feeding fail to provide these defences; and usually combine 
against the infant poor nutrition, absence of immunization, and 
exposure to the five routes of infection. Great skill and care 
and constant watchfulness may serve in artificial feeding par- 
tially to offset these dangers; breast-feeding automatically pro- 
tects against them almost without effort. Moreover, breast-feed- 
ing accomplishes in other ways four times the service in saving 



86 THE NEW PUBLIC HEALTH 

may reach it. But, as we do not know how to teach 
sheep to fight, so we do not know the laws of health 
needed for this purpose if any such exist. 7 Such meth- 
ods tested against infection have generally failed 8 so 
far. In that day when sheep fight wolves they may 
succeed. 

Those who believe that the sheep may be taught to 
dodge the wolves have much more in their favor. 

Dodging infection is well understood. The phy- 
sician, the nurse, the epidemiologist, handle with im- 
punity the very sources of infection themselves, — in- 
fected persons and their infected discharges. Why not 
teach this art to every citizen ? The principle is sim- 
ple, — prevent infected discharges from entering the 
mouth. It is in the practising of this principle, simple 
as it is, that the inexperienced person fails. A single 
slip may be fatal, and slips are constantly made. More- 
infants' lives that it accomplishes in cutting out infectious dis- 
eases. (The writer wishes to record his indebtedness to Dr. 
J. P. Sedgwick, of Minneapolis, for much valuable information 
on this subject.) 

7 Once more we beg our readers not to think that, because 
building up the body cannot make it proof against infectious 
diseases, building up the body should be abandoned. To say 
that physical care of the body never made a Newton or a Shake- 
speare is not to say that no man need care for his physical 
welfare. The laws of physical health, even so little as we know 
of them, have many virtues. Because protection from infectious 
diseases is not one of them detracts no whit from any of the 
others. 

s Tuberculosis and pneumonia are often held exceptions to this 
rule, but that they are exceptions is being questioned. 



THE NEWEST PRACTICE 87 

over, to guard against those infected persons who are 
not recognized as such, means that all discharges must 
be kept out of all mouths at all times, — a theoretically 
possible, but, to the vast majority of the work-a-day 
world, a practically wholly impossible, performance. 
If we give up in despair the hope of excluding all dis- 
charges from all mouths and attempt to teach the ordi- 
nary citizen to recognize infection so that he may avoid 
at least infected discharges, we shall be attempting to 
make of each citizen, man, woman, and child, a highly 
trained physician. To teach personal defense against 
infection is a great thing for those who have the oppor- 
tunity to learn and the incentive to practice it. As a 
general method for abolishing infectious diseases it is 
quite hopeless ; nevertheless, each citizen should have the 
chance to know at least the principles and these should 
be taught in every school in the land. 

Those who believe that infectious disease should be 
warded off by specific immunization have some sure 
ground to go upon ; but the scope of immunization is at 
present small. These are they who would build wolf- 
proof folds; but we do not know how to build folds 
which will be proof against all kinds of these wolves. 
It is true we know how to build a fold which is proof 
against smallpox, and that is vaccination. Also we have 
lately completed a fold proof against typhoid, which is 
antityphoid inoculation. But, alas, granting such folds 
are built, driving the sheep into them is a procedure , 
forbidden to public health, except under martial law. 



88 THE NEW PUBLIC HEALTH 

In vaccination and in antityphoid inoculation the old 
adage still applies: "First catch your sheep." 

Those who believe in guarding routes of infection are 
those who would patrol the approaches to the sheep. 
This is at least a possible method, already established as 
of great value in some diseases. But a consideration of 
the following table shows that, like immunization, its 
scope is limited. Its scope is broader than that of im- 
munization, but it is not broad enough to cover all in- 
fectious diseases. 

If we tabulate the different infectious diseases occur- 
ring in the temperate zone on the .basis of their chief 
routes of transmission we find that water, food, flies, 
and milk are the main public routes ; the many private 
routes we group under contact; but not every route 
operates in every disease. Thus: 

The Chief Infectious Diseases of the Temperate Zone classi- 
fied by their Chief Routes of Infection 

Typhoid fever (and other 

intestinal infections) 

are carried chiefly by . . . .water; food; flies; milk; contact. 
Tuberculosis (human) 9 is 

carried chiefly by flies; 10 milk; contact. 

9 Bovine tuberculosis is of course derived chiefly from the 
milk of tuberculous cows. In many ways this disease is best 
separated for administrative purposes from human tuberculosis. 
The carriage of human tuberculosis in milk referred to in the 
table is that dependent on the infection of milk by tuberculous 
milk handlers. 

10 Insignificant. 



THE NEWEST PEACTICE 89 

Diphtheria, scarlet fe- 
ver, measles, German 
measles, mumps, 
whooping-cough, small- 
pox, chickenpox are 
carried chiefly by milk ; contact. 

Syphilis, gonorrhea, 
trachoma, cerebro-spinal 
meningitis, leprosy are 
carried chiefly by contact 

Hence water and food, as great public routes of com- 
munity infections, carry only the intestinal infectious 
diseases. Flies, practically speaking, also carry this 
group only, the amount of tuberculosis carried by flies 
being small. Milk carries many infectious diseases, but 
contact alone carries all. 

If we guard only water supplies against infection, we 
eliminate water-borne intestinal infections (this, so far 
as typhoid is concerned, would be perhaps one-third of 
the total typhoid in America). We leave untouched 
intestinal infections carried by food, flies, milk, and 
contact. Also we leave untouched all other infectious 
diseases. 11 If we guard food, as well as water, we 
eliminate such intestinal infections as are carried by 
food and water, but the fly, milk, and contact routes for 
these remain; so do all routes which carry the other 
infectious diseases. 

11 Hazen's theorem — that infected water supplies carry all the 
infectious diseases — is an unproved and much disputed hypoth- 
esis as yet. 



90 THE NEW PUBLIC HEALTH 

If we eliminate flies also, fly typhoid and its con- 
geners go, but milk and contact typhoid still remain 
with us. It is true that a slight effect on tuberculosis 
also might be noted, but nothing else is touched. If we 
guard milk supplies against infection, 12 we begin to 
make great strides, but contact, the great route of human 
tuberculosis and of all the other infectious diseases, in- 
cluding the intestinal, still will operate. 

. The fact is that while public water, food, fly, and 
milk infections parallel invasion by wolves coming from 
without, contact infection parallels the presence amongst 
the sheep themselves, of " wolves in sheep's clothing." 
Such wolves, because intermingled with the sheep, can- 
not possibly be eliminated by guarding the approaches. 

If, then, the guarding of public routes can exclude 
only some of the infection, what remains ? 

The extermination of all the wolves — the abolition 
of the sources of infection. 

If our modern wolf -hunters can find the undisguised 
wolves and even the wolves in sheep's clothing, after 
the sheep are slain, why cannot they find them also 
before the sheep are slain ? If the very sources of in- 
fection (known cases, missed cases, and carriers) can- 

12 A great deal of the alleged milk supervision of to-day to 
prevent watering or to keep up the fat standard has no relation 
whatever to guarding milk against infection. Even the campaign 
for clean milk eliminates dirt chiefly. Unless especially con- 
ducted to prevent infection, it fails on this latter score com- 
pletely. Most public health authorities now recommend heating 
even the " cleanest " milk as the only real safeguard. 



THE NEWEST PRACTICE 91 

not escape our epidemiologists armed with their mod- 
ern principles, why wait for an epidemic before we go 
after them at all ? 

Turn again to the table and see that if we begin oper- 
ations for control with water, we must move through 
food and flies and milk to contact before we have in- 
cluded all even of typhoid ; and until we reach contact, 
we do not begin to touch the bulk of the other diseases 
at all. But if we begin with control of contact, we 
find that the method which eliminates contact infection 
necessarily eliminates the other forms also. That 
method when shorn of non-essentials is the supervision 
of all infectious persons. 

THE NEW PEOGRA3M 

To drop metaphors, the new program of official pub- 
lic health is the abolition of the infectious diseases. 

The measures proposed for this purpose in progres- 
sive order of general efficiency, from lowest to highest, 
are — 

1. The securing to each individual citizen continu- 
ously of his highest possible general physical health. 
Ideal as this is as an end in itself, it can have little 
effect on most infectious diseases, except indirectly dur- 
ing infancy, although it is acclaimed as a factor in re- 
ducing tuberculosis and pneumonia even in adults. 

2. The securing to each individual citizen of instruc- 
tion and training in the personal conduct which he must 
follow in order to avoid receiving into his body the dis- 



92 THE NEW PUBLIC HEALTH 

charges of infected persons. This as a system is per- 
fect, but the securing of the daily carrying out by every 
one of the personal conduct needed is a hopeless dream. 

3. The securing to each individual of continuous spe- 
cific immunization. Technically practical as yet only 
against smallpox and typhoid fever by inoculation, and 
in infancy against certain infections by breast-feeding, 
the scope of this procedure is very limited ; and it must 
be remembered that the public have never yet adopted 
even smallpox immunization, except under compulsion, 
to an extent sufficient to abolish even this one disease. 

These three measures place the abolition of infection 
directly upon the individual, as though, to abolish foot- 
pads, we should arm each citizen and train him in 
jiu jitsu; or as though, because of one free wolf, we 
should put five hundred sheep in armor. The three 
measures which follow place the abolition of infection 
directly upon a very small group of experts who deal 
directly with the infection itself. These three measures 
would put the one wolf in bonds, and let the five hun- 
dred sheep go free. 

4. The physical supervision of the four great public 
routes of infection (public water supplies, public food 
supplies, flies, which are public property, and public 
milk supplies) to exclude all discharges from them. 
The principles are well understood, but, in practice, 
systematic application usually is lacking. (Physical 
supervision of such public and private surroundings as, 
by their effect on conduct, may bear on the operation 



THE NEWEST PRACTICE 93 

of the fifth and greatest route of all, i.e., contact, now 
more or less efficiently attempted in housing and settle- 
ment movements, is necessarily at present more a matter 
of education than of official action, especially where pri- 
vate surroundings are involved.) 

5. The physical supervision of all known infectious 
cases to exclude their infected discharges from all routes. 
This, thoroughly done, would make a tremendous im- 
pression on infectious disease. But known cases form 
not more than half the total sources of infection. 

6. The sociological supervision of all infectious per- 
sons. These are the sources of infectious diseases. 
Once found and supervised, infection from the human 
must stop in toto. 

Eor the first three measures, education, demonstra- 
tion, persuasion, are the things required; but also the 
abolition of carelessness, poverty, and the pressure of 
necessity. Knowledge alone is not enough; time and 
facilities to do with are needed also. To supply all 
these to every citizen, man, woman and child, is an ideal 
to be sought by every path ; but an ideal that will take 
long years to realize. 

For the second three we have principles and practice, 
precedent, authority, some law, and the hearty support 
of public opinion in epidemics. We need a few new 
laws. Chiefly we need proper organization and in- 
creased equipment ; but, more than all, the hearty sup- 
port of public opinion, continuously, not in epidemics 
only. 



94 THE NEW PUBLIC HEALTH 

Of all these measures, the last is certainly the most 
inclusive; properly done, it excludes the need (so far as 
abolition of infectious diseases is concerned) of all the 
others. It is cheaper, simpler, easier, more direct and 
rapid than any other, and does not " interfere " with 
every citizen, in every act of daily life, indefinitely, for 
it deals with but one small class (infected persons), and 
only while infective; and it deals, even with them, 
merely to the extent of preventing the spread to others 
of their infected discharges. 



CHAPTER IX 
INDIVIDUAL DEFENSE 

PUBLIC DEFENSE AISTD PKIVATE 

The preceding chapter distinguished sharply those 
things necessary to escape existing chances of infection, 
which individuals may do, from those things necessary 
to prevent chances of infection from existing at all, 
which latter communities must do, if it be done at all, 
because individuals cannot. 

The present chapter will outline the former, the in- 
dividual's part in protecting himself. As already indi- 
cated, these individual efforts may be made in three 
directions : 

1. To secure high general physical health. 

2. To secure specific immunity to specific diseases. 

3. To avoid disease, especially infectious disease. 

Efforts made in the first direction aim to build up 
and make palaces of the bodies in which we dwell and 
which, too often, are mere hovels; but, alas, the non- 
fireproof palace burns as easily as the non-fireproof 
hovel. It is futile to seek the physical advancement of 
the race in order to abolish disease. We should seek 

95 



96 THE NEW PUBLIC HEALTH 

the abolition of disease in order to physically advance 
the race. 1 

THE PKEVENTABILITY OF THE " PREVENTABLE " 
DISEASES 

True, we should not await the abolition of disease be- 
fore seeking general physical advancement, but, unfor- 
tunately for the achievement of very much real progress 

n No greater fallacy burdens public health advance than the 
idea that high health protects against infection. Every health 
officer scouts this idea when it is presented to him by an anti- 
vaccinationist to show that vaccination is unnecessary — scouts 
it when it is offered as an excuse for neglecting quarantine — 
scouts it when father, mother, nurse, wife, husband urge it as 
a reason why he or she, untrained in self-protection, should brave 
infection at the side of a loved one. Yet almost every health 
officer will urge it in his next bulletin or in his next address! 
The statement that high health is an efficient protection against 
infection is either true or not true. When athletes, soldiers in 
the pink of condition, lumbermen, fail to succumb to syphilis, 
gonorrhea, typhoid, pneumonia, it will be time to consider high 
health as a possible reason for their escape. Until that time this 
wretched quibble should be abandoned by all who hope to teach 
the truth according to the evidence. 

The Agricultural colleges and experiment stations, dealing 
with the physical development of stock animals to the highest 
point, have found that such high physical development does not 
prevent or minimize infection. It is high grade stock, rather 
than scrub, which suffers infections. Immunity to certain 
diseases has been secured by careful breeding amongst plants 
(rustless wheat for instance), but not amongst animals to any 
practical extent. (Permission to quote their names in support 
of this footnote has been granted by Dean A. F. Woods of the 
University of Minnesota Agricultural Department, and by Prin- 
cipal F. C. Harrison of the MacDonald College, Quebec.) 



INDIVIDUAL DEFENSE 97 

in this line, we know as yet few practicable rules of 
general application, except for infants, to achieve such 
physical advancement. Far better than how to secure 
high physical health we know how to avoid disease, at 
least, how to avoid certain diseases. A few of these are 
non-infectious environmental diseases, like scurvy and 
miner's elbow; and the non-infectious poisonings, like 
those from lead, arsenic, phosphorus, alcohol, and illu- 
minating gas. These diseases depend upon readily rec- 
ognized mechanical or physical surroundings. A change 
of diet in scurvy or of position in miner's elbow ; stop- 
ping leaks in pipes for illuminating gas poisoning; 
refusal to admit the other poisons to the body — and 
all are abolished. But after all, these non-infectious 
poisons furnish but 1 in 1,000 of all deaths, except in 
infancy, where non-infectious intestinal poisonings 
probably furnish a large proportion. 

On the other hand, the poisonings which are infec- 
tious, i.e., the infectious diseases, furnish more than 
one-sixth of all the deaths, and about one-half of these 
deaths are from but one infectious disease, namely, con- 
sumption. Like the chemical poisonings, — lead, arse- 
nic, etc., — the infectious diseases depend on noxious 
materials that enter the body. But, unlike lead, arse- 
nic, etc., the poisons which produce the infectious dis- 
eases are associated, not with a few well-known material 
surroundings and inanimate things, but with the living 
activities of many, often unknown, persons. 

The little we know of how to achieve high health, and 



98 THE NEW PUBLIC HEALTH 

the much more we know of how to avoid disease, should 
be taught our many million citizens. This huge task 
requires a mechanism so huge that only our huge public 
school system can accomplish it. 2 

Efforts in the second direction (for specific immuniza- 
tion) aim to " fireproof " our bodies against disease, 
whether those bodies be " palaces " or " hovels." But 
such fireproofing can as yet be done only against small- 
pox and typhoid fever. 3 

Also, just as the general public will not fireproof 
literal houses against literal fire, despite large fire losses 
every year, so the general public will not fireproof their 
bodies against infection, even against smallpox. One 

2 It is often said that practicing physicians should teach health 
to the public. In one sense this is true. Physicians represent 
medicine, and medicine deals with disease, its cure and its pre- 
vention. But practicing engineers might as well be drafted to 
teach geometry as practicing physicians to teach personal hy- 
giene. Physicians dealing with their own patients, or even 
lecturing or writing on these subjects, do much good. Such work, 
however, is but a drop in the bucket, reaching only a fraction 
of the public and generally just that fraction which needs it 
least. There are over 100,000 practicing physicians in America. 
They have not time, training, organization, or authority for the 
sort of teaching that will really reach all citizens; the public 
school system has all four, and nearly a million teachers to do it 
with. 

Medicine must furnish the facts that are to be taught, but 
it is quite impossible that practising physicians should do the 
teaching. 

s The immunity possible against diphtheria through protective 
doses of diphtheria antitoxin, is too short-lived for general con- 
tinuous application to all citizens. 



INDIVIDUAL DEFENSE 99 

hundred years of vaccination has left us with only 30 
per cent, of children under 16 years of age protected 
against smallpox. We shall be lucky if 10 years of 
antityphoid inoculation finds us with 10 per cent, of 
adults protected against typhoid. In the absence of 
compulsory laws, rigorously enforced, immunization 
must remain a task of systematic education, reaching 
every one, and this task also only the public school sys- 
tem can properly perform. 

Efforts in the third direction aim to shut out all poi- 
sons, including all infections, from all bodies, whether 
these bodies be palaces or hovels, on the principle that 
as no dwelling, palace or hovel, can burn if fire do not 
reach it, so our bodies, good, bad, or indifferent, cannot 
be destroyed by disease if the causes of disease be shut 
out from them. To abolish literal fire from literal 
dwellings is impracticable, for fire is too useful for such 
abolition. Disease serves no useful purpose, and its 
abolition is the only reasonable goal. 

The exclusion of the poisons of disease, infectious or 
non-infectious, from the body, is the most successful 
preventive measure we have at present against most dis- 
eases that are preventable at all. The methods should 
be taught to every citizen ; and for this again the public 
school system alone is able. Public health experts must 
supply the facts ; it is quite impossible that they should 
do the teaching. 4 

4 Of each 1,000 school children 450 leave school at the end of 
the 6th grade work, 450 leave at the end of the 8th grade. The 



100 THE KEW PUBLIC HEALTH 

" DODGING INFECTION " 

" Dodging infection " rests on simple principles, al- 
ready outlined. The one essential is to exclude from 
entrance to the body, matter from infectious bodies, i.e., 
in briefest practical form, to exclude from the body, 
usually from the mouth, the infected discharges of 
others? 

To do this requires, first, the ability to recognize in- 
fectious persons; and, second, the skill to avoid their 
discharges. But we cannot teach the general public, 
half of them children, to recognize infectious persons. 
If, then, we broaden the rule and teach avoidance of 
discharges of all sick persons, whether infectious or not, 
we ignore those persons who are infectious without being 
sick. Hence, for the non-medical citizen, the rule must 
run: Exclude all discharges of all persons from all 

remaining 100 enter the high school; but only 50 graduate. 
Ten out of the thousand enter the University; 5 graduate. We 
now teach in the earlier grades theoretical anatomy and theoreti- 
cal physiology, intending thus to form foundations for later 
practical information. Since 90 per cent, of children leave at or 
before the 8th grade, this 90 per cent, receive the theoretical 
information only; they never learn its practical use at all. 

This system needs inversion. We should teach the practical 
parts of hygiene and of avoidance of disease to the 100 per cent, 
of children, i.e., not later than the 6th grade, leaving the the- 
oretical parts for the 10 per cent, that take the higher courses. 

5 Plague, malaria, yellow fever, typhus are, in most cases, the 
results of bites of insects infected from infectious bodies. The 
principle is the same although the modes of transmission 
differ. 



INDIVIDUAL DEFENSE 101 

bodies, especially the mouth. But this is by no means 
so easy as it sounds. 

CONTACT-INFECTION 

The mouth-discharges of our associates are constantly 
entering our bodies in the form of mouth-spray, of 
sputum, and of smears on various things, but chiefly by 
smears on hands. 

Mouth-spray consists of tiny, often microscopic, drops 
of liquid from the mouth, thrown out in sneezing, 
coughing, shouting, singing, and speaking, but not in 
quiet breathing. The larger ones can be seen, if 
watched for, and they can be felt falling upon the face 
during close face-to-face conversations. Talk, or sing, 
or shout, or cough, or sneeze against a mirror two feet 
distant, and count the drops that strike it. Then pic- 
ture to yourself what happens at " teas " and " so- 
ciables " ; at meals, with lively conversation going on ; 
at school ; at church. Think also of what happens when 
cooks or waiters talk while preparing food, cough while 
laying tables, or sneeze while wiping dishes. 

This distribution of mouth-spray cannot be prevented 
unless all wear masks, as modern surgeons do when oper- 
ating. 

But the intaking of mouth-spray may be avoided 
somewhat by avoiding close face-to-face conversations, 
as by sitting side by side or far apart ; its distribution 
to others by coughing or sneezing always into a hand- 
kerchief, etc. Often, of course, the cough or sneeze 



102 THE NEW PUBLIC HEALTH 

comes too quickly or the hands are already full. It is 
true that the head may be turned aside ; but often this 
spares the person in front at the expense of others, and, 
while coughing or sneezing into the hand prevents the 
mouth-spray from flying wide, the spray goes to the hand 
and the hand itself passes it on to other persons 
later. 

There is no practical method of avoiding all mouth- 
spray of associates, except not to have associates ; but the 
amount of exchange may be diminished by the above 
precautions. 

Sputum, through the spitting habit, falls upon floors, 
steps, sidewalks. That these deposits dry and blow 
about as dust is the least of the dangers, especially out 
of doors, for sunlight and drying disable most disease 
germs. Sputum follows a much more important route 
leading to mouths, and this route is followed, not when 
the sputum has become dry and dusty, but while it is 
still fresh and moist, — while disease germs which may 
be in it are still living. This route is by way of shoes, 
directly into houses. There, wiped off on carpets, it 
awaits the creeping baby ; it smears itself on the baby's 
fingers; and they carry it directly into his mouth. 
Also, the owner of the shoes uses his fingers in remov- 
ing shoes, and then, too often, the owner's fingers, just 
like the baby's, enter the mouth unwashed. The value 
of anti-spitting ordinances thus becomes apparent. 

But, after all, hands are the great route of exchange, 
and hands furnish the great route for bladder, 



INDIVIDUAL DEFENSE 103 

bowel and other discharges, as well as for nose and 
mouth. 6 

From birth to death those universal tools, our hands, 
go to our mouths incessantly; from birth to death we 
use them for every other purpose also. Hands encoun- 
ter all the discharges of the body many times a day; 
and if not scrupulously washed on every such occasion, 
they carry these discharges to everything they touch, 
including other hands, which go to other mouths. The 
very handkerchiefs we advocate to cough or sneeze or 
blow our noses into, transfer these same discharges to 
our fingers, the next time that we use them. 7 Then we 
shake hands with others, or feel the baby's new tooth. 

Visits to toilets, unless followed at once by careful 
hand-washing, mean similar transfer of the toilet dis- 
charges as well, particularly amongst children, who, re- 
member, form nearly half the population. 

The common drinking-cup and the common drinking- 
pail are bad because they help to exchange mouth-dis- 
charges ; the roller-towel is worse, especially when used 
for half-washed hands, because then it helps to exchange 
all the bodily discharges ; but the unwashed hands them- 
selves are worst of all, because the discharges they carry 
are undiluted and fresh and moist and warm. When 

e Hands do not carry infectious diseases only. They are the 
chief routes by which lead is carried to mouths in lead-poisoning, 
and are also an important factor in phosphorus poisoning. 

7 It has been suggested that the left hand should be used for 
handkerchiefs, thus leaving the right hand clean so far as these 
discharges are concerned. 



104 THE NEW PUBLIC HEALTH 

strangers enter a household, they add, through mouth- 
spray and hands, their discharges to the general house- 
hold stock ; and, in this way, harvesting help, threshing 
crews, etc., introduce infectious disease into numerous 
rural families and communities every year. 

Within the purview of the private citizen at home, 
discharges are also exchanged somewhat through things 
soiled by mouth-spray and hands, as well as directly. 
Thus are contaminated dishes in laying the table, bread, 
cake, etc., also pillow-cases and sheets which are soiled 
by mouth or other discharges from the body. The list 
of the things which may carry such discharges is too 
long for itemizing here; but, in general, such things 
do not form really very important routes of transfer, 
except when the discharges are considerable in quantity 
and while the discharges are fresh and moist. Once 
dried on clothing, mouth-spray, for instance, is not 
readily set free, and when it is dry, infection, if pres- 
ent, dies out with fair rapidity. Just as the main pub- 
lic routes of discharges from the community to the fam- 
ily are public water supplies, public food supplies, pub- 
lic milk supplies, and public outdoor flies, so the main 
private routes within the family, apart from mouth- 
spray, sputum, and hands, are private water supplies, 
private food supplies, private milk supplies, and private 
indoor flies. Public supplies may or may not bring dis- 
charges with them to the family; once they enter the 
family, they pretty surely receive the family discharges 
from the family itself. So also with the private sup- 



INDIVIDUAL DEFENSE 105 

plies of the same things ; the family well may or may 
not be dosed with the family discharges; the family 
drinking-pail or pitcher almost always is; the family 
cow may or may not contribute discharges to the family 
milk-pail, but the family milker practically always 
does ; 8 and later, within the family, the family milk- 
pitcher receives the family mouth-spray. The family 
food, before and even after cooking, is subject to similar 
contamination. The family flies moving from the out- 
door toilet, unless it be fly-proof, or from indoor spit- 
toons or slops to food, aid in the same exchange. 9 

To know these dangers means half the battle won. 

s If a milker talks or sings or coughs or sneezes, using a wide 
mouth pail, his mouth discharges enter the milk. If he milks 
with unwashed hands, all his discharges enter the milk also. 

9 A curious perversity of human nature makes us attach un- 
due importance to many possible but unimportant routes of dis- 
charges, like telephone-receivers, dirty money, the licking of 
postage stamps, etc., while we neglect the commonplace, really 
important routes, acting daily and everywhere, above outlined. 

An example of the same thing is seen in the great anxiety ex- 
pressed concerning meat as a route of infection. It seems to be 
remembered but seldom that meat is almost always cooked, i.e., 
it almost always automatically receives the very treatment we 
solicitously prescribe for blocking infection through milk and 
through water. Meat-inspection is wholly proper, to secure good 
meat, and to prevent the robbing of the consumer's pocket and 
the consumer's stomach. But all the meat-inspection in the 
world could not reduce our ordinary infectious diseases by one- 
tenth of 1 per cent. Meat, as food, especially cold meat, often 
carries the family discharges, but disease in, or discharges at- 
tached to, meat from its sources outside the family, are in most 
cases destroyed by cooking. 



106 THE NEW PUBLIC HEALTH 

Against infection of public routes, — public water sup- 
plies, public food supplies, public outdoor flies, and pub- 
lic milk supplies, — the private citizen should not need 
precautions, for these the community itself should 
guard. But if he need them, the private citizen has 
against such public routes two powerful weapons: (a) 
exclusion from his premises of the infected material, 
and (b) cooking. Foods are, of course, usually cooked, 
even in ordinary life ; water may be boiled, milk heated, 
and if flies cannot be excluded, the food they contami- 
nate can be rejected or cooked again. 

The public routes of infection are not difficult for 
the citizen to guard against, however wearisome that 
guarding may be ; the real difficulty is with the private 
routes, those routes of contact that carry infection within 
the family and also within the school, the office, the 
workshop, the factory. We, individually or collec- 
tively, may abolish in time the common drinking-cup 
and common roller-towel, but no one can ever abolish 
mouth-spray or hands throughout the race. 10 

It is true that by education u we may greatly affect 

10 One hundred million mouths, served by 200,000,000 hands, 
receive 300,000,000 meals in America daily. But these hands 
are not as important as are the hands that handle the meals in 
preparation; moreover, hands go to mouths far more often be- 
tween meals than during them. 

ii The following rules prepared for use in the public schools 
at the request of County Superintendent Geo. S. Selke, Benton 
County, Minnesota, indicate the main points to be taught con- 
cerning protection from infectious diseases in the schools. They 
indicate also pretty closely what can be done in the home and for 



INDIVIDUAL DEFENSE 107 

personal conduct, but to leave the abolition of infection 
in ordinary life to the personal conduct of all sorts of 
people, half of them children, would be as wise as to 

this reason they are inserted here. (Now printed and distributed 
to Minnesota Schools by the State Department of Education.) 

Placard for Schools 
The germs of infectious diseases are in the discharges of in- 
fectious persons. Infectious diseases are " caught " from infec- 
tious persons simply by taking into the mouth some portion, 
usually very small, of their infected discharges. 

The Great Rules of Prevention in Schools 

1. Exclude from school all infectious persons, thus excluding 
all infectious discharges. 

2. Since infectious persons may enter school at times despite 
the greatest vigilance, restrict, so far as possible, the scattering 
of any discharge of any person at any time in school. (This will 
also train the children to restrict their discharges out of school 
and in after-life.) 

a. Mouth discharges are transferred directly to and taken di- 
rectly from drinking-cups, towels, pencils, chewing-gum, whistles, 
etc. Mouth, nose, bladder, and bowel discharges are transferred 
directly to hands many times daily. Hands go to mouths many 
times daily; therefore — 

Provide individual drinking-cups, individual towels, individual 
pencils, individual modeling-clay, individual modeling-sand, etc. 
( There should be a sign in every school, " Wash your hands after 
every visit to a toilet.") 

b. Sputum (spit) or other discharges, deposited on floors, 
sidewalks, etc., are picked up by shoes and so carried into homes. 
When handling shoes (putting on, taking off, etc.), discharges 
are transferred to hands, which go to mouths, or touch things 
that go to mouths. Therefore — 

Avoid depositing discharges, — sputum, etc., — on floors, side- 
walks, or elsewhere where other people may step on them. 



108 THE NEW PUBLIC HEALTH 

trust the destruction of infection in a water-borne ty- 
phoid outbreak to the boiling of the water by private 
citizens. 

e. Mouth-spray is thrown out in talking, singing, coughing, 
sneezing, etc., therefore — 

Avoid throwing mouth-spray into other people's faces by avoid- 
ing close face-to-face conversation, face-to-face recitations, face- 
to-face singing-exercises, etc. Cough, sneeze, etc., into a handker- 
chief always. 

d. The air of a schoolroom in use necessarily receives mouth- 
spray into it in talking, reciting, etc. 

e. Bladder and bowel discharges are carried by flies when flies 
can get at them. During early autumn and late spring or sum- 
mer sessions, flies may carry these discharges from toilets to 
children's lunches, etc., therefore — 

Make toilet-vaults fly-proof. Provide springs or weights to 
automatically close toilet-doors, and fly-screens for toilet-windows. 

f. Three things destroy comfort and success in school work: 
Temperature too high; Atmosphere too dry; Air not in motion. 
Also, no child can work well in a poorly lighted room; but do 
not imagine that good lighting, good heating, and good ventila- 
tion will prevent spread of infection if infectious persons gain 
entrance. No school is a sanitary school if the children ex- 
change their discharges without restriction ; but only those schools 
where infectious persons are watched for and excluded are safe 
schools, therefore — 

Note daily the general state of health of each child. No child 
who shows any decided change from the usual for that child, 
especially fever, headache, sore throat, stomach-ache, or general 
dumpishness, should attend school until seen by a physician. 
This rule permits early detection of infectious children. It also 
excludes children who should be excluded for their own good, 
even if non-infectious. 

g. Children showing defective vision, hearing, breathing, etc., 
should be referred to the principal, superintendent, or school 
board for action. 



INDIVIDUAL DEFENSE 109 

All health officers know that adults in large propor- 
tion will not, and many children cannot, boil the water. 
Moreover, the law (in Minnesota) now recognizes that 
the community has no right to supply water of such a 
kind that the consumer must protect himself against it. 
This principle should be extended, so that the commu- 
nity is held responsible for infection carried by any 
public route, — food, milk, or flies, — as well as by pub- 
lic water. Some day the equally logical step should 
follow, — the holding of the community responsible for 
all infectious diseases, by whatever routes they travel, 
including contact. The community, thanks to modern 
science, can abolish the sources of all infectious diseases ; 
and once the sources are abolished, the diseases, being 
non-existent, cannot travel by any route, even by con- 
tact. 

The simple fact is, that the private citizen in his own 
home can protect himself against public routes of dis- 
charges as just outlined and from the family discharges 
to some extent; but the moment he leaves home and 
enters into relations with the general public, his indi- 
vidual control is at an end. He cannot guard, generally 
he cannot even ascertain, the sources or routes of the 
water, milk, food, or flies he must encounter. Above 
all, he cannot guard the sources or routes of the dis- 
charges furnished by the persons he necessarily meets. 
His children go to school, compelled directly by the law 
to do so, and there they share discharges which no per- 
sonal defense through conduct can wholly avoid. He 



110 THE NEW PUBLIC HEALTH 

goes himself to work, compelled indirectly by the law 
to do so, and there he shares discharges which he can 
little or not at all control. Only the community can 
exclude infection from the public routes of discharges, 
water, milk, food, and flies; but also only the commu- 
nity can exclude infection from the private routes of 
discharges grouped under " contact " ; for only the com- 
munity can exercise such control over those already in- 
fected as to prevent them distributing their infection. 

Of course, the exchange of discharges already out- 
lined, however inevitable, is harmless unless and until 
infected discharges enter into the exchange. The 
chances of encountering infected discharges can be ap- 
proximated somewhat from the supposition that daily 
there goes at large, unknown, say one infective person 
in each 500 of the population. Hence, he who would 
defend himself from infection by his habitual personal 
conduct toward his associates must avoid the harmless 
discharges of 499 uninfected persons in order to avoid 
the harmful discharges of one unknown infected person. 
(This estimate is necessarily a guess, and it does not 
include the venereal infections.) 

The great weakness of the personal defense through 
conduct is this: The precise moment when it is most 
needed is the precise moment when it generally fails. 
In the first place, the mouth-spray of the ordinary well 
person is not half so abundant or so widely scattered as 
that of the case of tuberculosis, of measles, of whoop- 
ing-cough, or of influenza, for these are just the diseases 



INDIVIDUAL DEFENSE 111 

in which coughing and sneezing are prominent symp- 
toms. The bowel-discharges of the ordinary well per- 
son are not half as likely to be disseminated as those 
of the typhoid or dysentery case, for these are just the 
diseases in which frequent, abundant liquid stools, often 
involuntary, occur. Again, the discharges of the well 
person are handled chiefly by that well person himself ; 
the discharges of the sick must often be handled by asso- 
ciates unused to performing such services for others. 
Finally, exactly as green troops forget under fire all 
their parade-ground drill, trip over their own feet, and 
fire into the ground or at the sun, so the citizen, how- 
ever carefully he may have practiced a well-thought-out 
system of avoiding discharges in ordinary life, goes all 
to pieces in the flurry when his child develops, say, scar- 
let fever. Of course, it is true that untried troops 
soon recover their parade-ground drill, even in the face 
of the enemy ; but they cannot do what seasoned troops 
can do, and the non-medical citizen can seldom protect 
himself in the face of infection as the trained con- 
tagious-disease nurse does, the physician, or the epidemi- 
ologist. Nevertheless, if he has previously known, and 
practiced even crudely, the necessary precautions, 12 he 
is in a much better position to defend himself. 

12 It is a fatal fallacy to believe in " general cleanliness " as a 
defense against infection. It is not the " general cleanliness n of 
surroundings that prevents infectious diseases ; it is the " specific 
cleanliness " of freedom from infected discharges. Scrubbed 
floors, bright pans, neatness, and order do not necessarily in- 
volve, usually do not imply, hands free of discharges; they 



112 THE NEW PUBLIC HEALTH 

SUMMARY 

The whole subject of public health divides itself 
into — 

1. Securing high physical development and efficiency. 

2. Avoiding disease. 

Of the former we know little of practical application 
to the general population except in infancy. 

Of the latter we know much of cure, but little of 
prevention, except in the environmental diseases, in the 
poisonings, as from lead, arsenic, alcohol, etc., and espe- 
cially in the infectious diseases. 

Defense against environmental diseases and the non- 
infectious poisonings is largely a matter of trade con- 
ditions and of avoiding dangerous, but known, non- 
living things and therefore largely of legislation, 
inspection, and conduct. Against infectious diseases, 
the sources being infected persons, defense is essentially 
a matter of precautions against those persons. The 
prime difficulty is the recognition of those persons. If 
they are not recognized, the defense becomes a matter 
of guarding against all persons. 

Defense against infection may be divided into indi- 
vidual and community defense. 

Infectious diseases are carried by four main public 

cannot stop mouth-spray. A gorgeous uniform no more shows 
ability to shoot than does " general cleanliness " show ability to 
avoid infection. It is not visible dirt that hurts, — mud, ashes, 
coal-dust, — but the usually invisible discharges in mouth-spray 
and on hands, and even these only when laden with infection. 



INDIVIDUAL DEFENSE 113 

routes — water, food, flies, and milk ; and by a fifth pri- 
vate route, contact. By cooking all alimentary sup- 
plies before eating them, the public routes may be 
guarded at the consumers' end, but public opinion and, 
in the matter of water supplies, the law (in Minnesota), 
rightly demand the transfer of this burden of protection 
to the producer. 

The private routes of contact can be guarded by the 
individual also, but only by a ritual so elaborate and 
covering so general a field that it does not adequately 
meet the ordinary conditions of the ordinary life of the 
ordinary citizen, especially of hard-working fathers, 
hard-driven mothers and young children. Contagious- 
disease experts, with long, patient training and when 
dealing with known infected individuals, generally suc- 
ceed; the ordinary untrained citizen must very often 
fail. 

Notwithstanding that the community can and should 
assume the prevention of contact-infection (by exclud- 
ing infection from the community entirely), in addition 
to the care, now very general, of the four public routes, 
the methods of personal defense should be well known 
to all ; and there exists no means of teaching them com- 
parable at all with the great public school system, for 
that, and that alone, reaches the citizens personally and 
in detail. There, in simple language, all that is useful 
can be readily taught, and it must be taught in the sixth 
grade, or earlier, to reach the population as a whole. 



CHAPTEE X 
COMMUNITY DEFENSE 

THE PUBLIC HEALTH ENGINEER 

The preceding chapter indicated the lines of personal 
defense against infectious disease which are available 
to the private citizen for his own protection through his 
own efforts. 

The present and succeeding chapters will deal with 
community defense, — those operations which, if prop- 
erly conducted by communities for the good of all, 
would make unnecessary the burdensome efforts of indi- 
viduals to protect themselves. 

The three great community measures for the abolition 
of infectious disease have been listed in increasing order 
of efficiency as — 

1. The protection of all public routes of infection, 

public water supplies, public food supplies, public milk 

supplies, and public flies. This is now done in some 

places to some extent. Usually it is but half done, 

chiefly for lack of proper understanding of what are real 

protective measures, or of proper organization for their 

execution; too often, also for lack of proper men to 

carry them out. 

114 



COMMUNITY DEFENSE 115 

2. The physical supervision of known cases of infec- 
tious diseases. This also is often now attempted. In- 
deed it is, on paper, the most developed of all. But its 
efficiency is cut down by lack of reporting, concealing 
of cases from and sometimes, alas, by physicians, etc., 
and especially by lack of sufficient trained experts in 
epidemiology to do the close-to-the-ground daily work. 

3. The sociological supervision of all infectious per- 
sons, already outlined in previous articles. 

The first of these items is dealt with here. 

For the protection of the public routes of infection 
three things are needed: proper physical construction, 
to exclude infection ; proper physical operation, to main- 
tain this exclusion; and the supervision of the human 
factor, — " the man behind the gun." A locomotive 
may be built perfectly and be kept in perfect running 
order; but the locomotive engineer himself is still the 
soul of the machine. Perfect physical equipment and 
perfect physical maintenance of public utilities related 
to the spread of disease, are enormously important, yet 
they are less important than the men who are to be in 
actual control of the actual operations. No better illus- 
tration of this can be offered than the fact that the milk 
supply from tested highbred cows, palatially housed, 
scrubbed, and vacuum-cleaned, has many times carried 
disease and death to the customers, because some one 
man engaged in handling the milk conveyed infection 
to it by the intimate personal contact which no organiza- 
tion or mechanism can wholly avoid. 



116 THE NEW PUBLIC HEALTH 

Some of the worst water epidemics we have ever had 
were due to the human factor failing at the critical mo- 
ment. This failure of the human factor, which is a 
commonplace in accidents by rail or boat, applies 
equally to all branches of public health, although the 
usual belief is that almost any person is good enough 
to conduct public health work. 

The reason for this commonly accepted belief is prob- 
ably that public health work for the prevention of dis- 
ease, or for the general physical advancement of the 
race, is often confused with certain measures which 
make merely for ease or comfort ; and it is human na- 
ture to look down upon those whose services minister to 
our comfort. We forget that by our slaves we rise and 
by our slaves we fall. Too often they and their pro- 
cedures are neglected so long as comfort and conven- 
ience are supplied by them without too much trouble 
to those who enjoy the fruits of their labor. 

To define public health engineering in the light of the 
new public health principles, it must be defined as such 
work as deals through the physical construction and 
operation of physical surroundings and mechanisms 
with (a) the prevention of disease or (b) with the ad- 
vancement of physical bodily welfare. If we include 
also, as is sometimes done, all such operations as con- 
duce, however indirectly, to any kind of " racial ad- 
vancement/' we must add all engineering works, archi- 
tecture, street paving, acoustic properties of public 
buildings, the size of doorways, fire-escapes, bridges, 



COMMUNITY DEFENSE 117 

railways, and every other form of modern artificial sur- 
roundings, and with them their corollaries, noise, dust, 
the smoke nuisance, etc. 

The line between true sanitary measures and those 
for securing mere comfort or convenience must be 
drawn somewhere, and it must be remembered that all 
" racial advances " are by no means advancements of 
public health. The railroads are of great sociological 
importance to the race, but they often carry disease 
faster or further than it would have traveled otherwise. 
Every advance which leads to greater prosperity leads 
also to more intermingling of people and to wider social 
relations and so involves a wider exchange of bodily dis- 
charges. The installation of a public water supply sys- 
tem adds great comfort, convenience, decency, and 
physical welfare, but it also provides a route of infec- 
tion theretofore non-existing, which leads directly into 
every home. If you put all your eggs into one such 
basket, you must watch that basket. A sewerage sys- 
tem, by getting rid of outdoor toilets, greatly conduces 
to decency, comfort, and cleanliness, and even obviates 
one danger of disease (carriage of toilet discharges by 
flies from the outdoor closet) ; but it also concentrates 
all those discharges into one foul union and the disposal 
of this often endangers other communities, and there is 
no real social advance in transferring the burden of 
infectious disease from one community to another by 
passing the sewage on from one water supply to an- 
other. Hence the true province of the Public Health 



118 THE NEW PUBLIC HEALTH 

Engineer is not the mere advocacy and construction of 
great engineering enterprises, but, rather, the super- 
vision of the construction of such, to see that the public 
health harm they may do, if the public health view be 
neglected, is properly avoided, so far as physical con- 
struction or operation may avoid it. 

The Public Health Engineer is not therefore, or, 
rather, should not be, merely what the popular imagina- 
tion makes him, a man of sewer pipes and concrete ; of 
water-meters, manholes, and pumps. The New Public 
Health Engineer will be a man keen of eye to see those 
features in all community construction work which may 
conduce to greater exchange of discharges, a man who 
knows just what is needed for prevention of disease in 
such ways, and therefore can both provide adequate 
precautions and at the same time avoid unnecessary 
or excessive ones. The civil engineer has been de- 
fined as he who can do for $1.00 what any fool can do 
for $4.00. He is a physical economist. He insists on 
physical safety, but within that limit knows best how to 
achieve the needed safety without undue expenditure. 
The Public Health Engineer, dealing with water sup- 
plies, sewage disposal, etc., does just this thing. He 
guarantees sanitary safety, and within that limit he 
guarantees it for less money than the ordinary builder. 
Any keen student of infectious diseases can generally 
see the grosser faults in a supply which permit infec- 
tion. The Public Health Engineer is a specialist. He 
sees these faults very much more quickly and surely ; if 



COMMUNITY DEFENSE 119 

they are intricate he has the skill and knowledge to dis- 
entangle them ; and when he finds them, he knows how 
to correct them. 

The Public Health Engineer is, or should be, much 
more than this, however. He is the only public health 
worker whose initial professional training necessarily 
makes of him a business man, in the sense of an ad- 
ministrator of operations on schedule time, and with 
economy of labor and expense. Those physicians who 
make good administrators in this sense do so because 
they learn it in administration, not because of initial 
professional training. This training of the Public 
Health Engineer makes him also the best man to super- 
vise maintenance of public utilities, as well as to con- 
struct and equip them. Further, the absence of train- 
ing in mechanisms and machinery so prominent in the 
training of most health officials, makes of the Public 
Health Engineer the only public health man who can 
deal properly with the many mechanical devices for 
modern handling of the public routes of infection, on 
the perfection of which many lives often depend. The 
hypochlorite plant, the mechanical filter, the pasteuriz- 
ing device are machines. However well a physician 
may understand the underlying biological principles, he 
cannot figure the pitch of a cog-wheel or find the reason 
of the filter " loss of head " without infinite and waste- 
ful effort, if at all. 

The Public Health Engineer is in public health what 
the surgeon is in medicine, the " man of his hands/'— 



120 THE NEW PUBLIC HEALTH 

the actual operator. Whatever the physician may dis- 
cover as surgically necessary to be done, it is the sur- 
geon who must bring his skill and knowledge to bear 
upon the doing of it. So, although the epidemiologist, 
the vital statistician, the laboratory man must usually 
determine the sources and routes of disease, it is the 
Public Health Engineer to whom all must turn wherever 
and whenever those sources or routes are to be put out of 
action by physical construction or mechanical device, or 
when economic maladministration of public utilities is 
the real basis of the trouble, rather than a physical 
condition. 

The Public Health Engineer is not, however, as a 
rule, a man of a biological turn of mind. He generally 
takes vital statistics too seriously and, lacking medical 
knowledge, interprets vital statistics too mechanically. 
His own units of weight, volume, and measurement are 
fixed and definite. He has not learned to scan the un- 
familiar units of disease, each by itself ; nor is it likely 
that as a class engineers ever will. The spectacle of an 
engineer advising on a strictly medical problem is only 
less sad, if less sad at all, than that of a medical man 
advising on a strictly engineering problem. It is by 
co-operation of these two, each perfect in his own field, 
but aiding the other with real understanding of the 
other's problem, that well-balanced, sane advance is 
made. 

So far as the five great routes are concerned, — water, 
food, milk, flies, and contact, — the engineer has as yet 



COMMUNITY DEFENSE 121 

found his chief field in dealing with water supplies. 
Even sewage disposal, so far as it is a sanitary problem, 
has as yet been chiefly considered in relation to 
the purity of water. But in the future the engineer 
must also deal with milk supplies, their produc- 
tion, transportation, pasteurization, disinfection; with 
the great fly problem and its chief corollary, the safe 
disposal of human excreta, as well as its minor corol- 
laries, garbage and manure removal. Finally, perhaps 
chiefly, he must deal with the great sociological factors 
on which rests contact infection in public meeting- 
places, — the factory, the shop, the church, the theater, 
the school, even the tenement and the private home. 
Above all, the great engineer of the future is he who 
will see with trained analytical mind and act with 
trained administrative ability in organizing or re-organ- 
izing not one but a dozen of the many factors in the 
modern complex of society, along lines which shall in 
themselves redistribute concentrated forces now too 
closely interwoven for mutual good. 

But there must be more public health in engineering 
rather than more engineering in public health. This 
little book will have failed wholly in pointing out 
the real essential inside truth of public health progress 
if it leaves any implication that infectious diseases can 
be abolished through any physical or mechanical means. 
The great engineering operations of the day have an im- 
portance to mankind much greater in sociological and 
economic lines than in public health. But the public 



122 THE NEW PUBLIC HEALTH 

health end must not be neglected, even though we recog- 
nize that it can never be the great end of engineering, 
because no mere guarding of such routes of infection 
can abolish disease, and, if it could, there are far more 
direct, drastic, and simple measures to be enforced in 
other directions than in the protection of public utilities. 
Great engineering works are not essential to the abo- 
lition of infectious diseases, but great engineering works 
should be so conducted as to secure what reduction in 
such diseases they may. The ultimate abolition of in- 
fectious diseases rests with the supervision of the infec- 
tious individual, and no mere adjustment of surround- 
ings practical for the race, can so affect his conduct as 
to compel that conduct along proper lines. But the 
public health engineer through housing, organization, 
and the proper construction and supervision of public 
utilities, can so design the lines of least resistance that 
the public, who generally follow these lines, will find 
them plain and smooth, but hedged about with iron 
walls of safety. 

SUMMARY 

It is a complete misnomer to designate as a sanitary 
engineer him who merely narrows his attention from 
the principles and practice of engineering in general to 
the application of these principles for the purpose of 
constructing water supplies, sewage-disposal systems, 
rendering of garbage, etc. 

A man is not a sanitary engineer because he can lay 



COMMUNITY DEFENSE 123 

down sewer pipe any more than a man is an artist be- 
cause he can lay on paint. The Public Health Engi- 
neer in the true sense is he who has acquired so wide a 
view of modern life, of its mechanisms, and of the 
physical side of man's environments, that he can see and 
act through them for man's physical protection, not 
merely from accident but also from disease. He does 
not just build sewers. When he builds them, he builds 
them as part of the great fabric of modern life. His 
plans are not merely so many feet of pipe, at such a 
price per foot ; they are adaptations and applications of 
great fundamental laws to the physical advancement of 
mankind. 



CHAPTER XI 
COMMUNITY DEFENSE 

THE PTTBEIOHEAI/TH LABORATORY 

Thei previous chapter discussed the relation of the 
Public Health engineer to the protection of man from 
disease, through the construction, operation, and direc- 
tion of those public utilities already proved to be, at 
times, routes of infection. 

Some day, when we have really determined the con- 
ditions which truly promote physical well-being, as dis- 
tinguished from those which merely secure escape from 
disease, the Public Health engineer will find larger 
functions in a wider field, the supervision of the whole 
material surroundings of man. 

The present chapter attempts to set forth the relation 
of the Public Health laboratory man to the same two 
divisions, — to the promotion of high health, on the one 
hand, and to the prevention of disease, on the other. 
Like the Public Health engineer, the Public Health 
laboratory man can as yet contribute but little to the 
former, and for the same reason, i.e., because so little is 
really known about it. Like the Public Health engi- 
neer, the Public Health laboratory man deals with the 

124 



COMMUNITY DEFENSE 125 

prevention of disease, and chiefly with the prevention of 
the infectious diseases. Again, like the engineer, the 
laboratory man deals in part with routes of diseases, 
with those public utilities which at times form highways 
for the exchange of infected, and uninfected, bodily dis- 
charges. But, unlike the engineer, his work is not con- 
fined to routes. 

The Public Health laboratory man, like the epidemi- 
ologist, deals also with sources, i.e., with the infected 
person. In some ways he goes further than the epi- 
demiologist, for he deals with the infected discharges 
themselves, rather than with the person who discharges 
them; and, not stopping even there, he deals with, in 
those discharges, the very principles of disease itself, — 
the individual little particles of living matter whose ac- 
tivities in the human system produce so much trouble 
for us all. 

This dealing intimately with the ultimate causes of 
disease is a fascinating, dangerous, peculiar life-work, 
an actual herding, and handling of the very essences of 
the dreaded plagues of old. What would not the an- 
cient philosophers and sages have given for one glimpse 
of a modern Public Health laboratory where matter-of- 
fact men handle, in their daily matter-of-fact routine, 
diphtheria plants, typhoid plants, tuberculosis plants, 
etc., quite as a student farmer handles potatoes or corn ? 

Because the little plants, or animals that produce 
many of our common diseases are as yet not actually 
known, for instance those of scarlet fever, measles, and 



126 THE NEW PUBLIC HEALTH 

smallpox, to name only three, the Public Health labora- 
tory man's chief daily duties lie with those diseases the 
germs of which are known, and therefore chiefly with 
the germs of typhoid, diphtheria, and tuberculosis. 
These furnish the bulk of his work. His chief services 
to mankind, in the temperate zone at least, consist in 
the aid he gives in recognizing those persons who are 
infected with one of these three germs without showing 
conclusive, perhaps any, symptoms of their presence. 
True, he can and does perform like services in other 
diseases whose germs are known — such as anthrax, 
bubonic plague, cholera, glanders, leprosy, etc. ; but 
these are so rare as to form only a flavoring for his daily 
grist. In the venereal diseases, also, the biological 
causes are known and can be recognized, but the labora- 
tory man must await the development of the growing 
public demand for the handling of these diseases on a 
par with other infections, the taking up of these great 
subjects by legislative and executive authorities. Until 
that time comes the laboratory man can proclaim his 
own readiness and point to the road, but he can do little 
more. 1 

With the routes of infection, — water, flies, food, 
milk, and contact, — the laboratory man has much to do, 
but, again and for similar reasons, he deals with these 
routes, in the temperate zone, chiefly when typhoid, 

i Laboratory tests for syphilis and gonorrhea are becoming 
recognized of late as Public Health laboratory duties. (See New 
York Health Department and others.) 



COMMUNITY DEFENSE 127 

diphtheria, or tuberculosis are involved. His functions 
in all this work are chiefly analytic, i.e., to find the par- 
ticular water, or milk, or food which may be danger- 
ous ; sometimes to detect, if he may, the presence in them 
of the deadly germ itself. 

Unfortunately, the laboratory, for reasons already 
offered in a different connection, can rarely find the 
germs of disease in water, food, milk, or flies. 
They live so short a life outside of the human, or ani- 
mal, bodies which form their natural growing-grounds 
that the laboratory man seldom encounters them except 
in the body. As a general thing, long before a " sam- 
ple " of water, etc., arrives at the laboratory, the dis- 
ease germs it may once have held are dead or so out- 
grown by others that the best laboratory methods must 
necessarily fail to find them. 

So little is this understood that one of the almost 
daily happenings in every laboratory is the receipt of 
water, or milk, or food (flies, fortunately, are not often 
sent, as yet) from laymen, even from physicians, with 
the request that they be searched for typhoid or diph- 
theria germs. 

But consider! Before a given water supply has at- 
tention called to it as a source of typhoid fever, typhoid 
fever cases usually must have developed from it. Now, 
typhoid fever is a disease which does not develop even 
its very first symptoms, until, on an average, two weeks 
have elapsed after the germs first entered the body from 
the water supply. Usually, another week passes before 



128 THE NEW PUBLIC HEALTH 

the physician is called and perhaps another week, more 
often two or three, before the sample is sent ; therefore 
five weeks is about the usual time which has slipped 
away since the typhoid germs were received by the pa- 
tient into his body from the water supply, before the 
laboratory man receives a sample from it! Now, two 
weeks is probably the usual maximum for typhoid germs 
to live in water, even if the water be stagnant and in a 
dark place. When it is heaving, changing, exposed to 
the sun and wind and current, or flowing fast, as in a 
river, the life of disease germs in it is even shorter, and 
the chances of their dispersion and disappearance by 
the mere physical losing of themselves are almost infi- 
nite. To apply laboratory methods to finding typhoid 
germs in the ordinary sample of water taken from the 
suspected supply five weeks after the cases were in- 
fected, would be like shooting at the place where a flock 
of ducks had been five weeks before. " Hunting for a 
needle in a haystack " is discouraging enough in itself, 
but suppose you knew the needle had been carefully 
removed before you began your hunt ! 

The laboratory man who examines water does so, not 
in the hope of finding typhoid germs, — he does not 
even try to look for them, as a rule, — but to find certain 
other signs of excretory pollution. Curiously enough, 
these signs are often of more real value to Public 
Health than would be the finding of the typhoid germs 
themselves, were that practicable; but to explain how 
this is, would be out of place here. The point is this : 



COMMUNITY DEFENSE 129 

The laboratory tests of the supposed routes of infection 
in any given case are made by methods and for ends 
wholly different from those which the public fondly 
imagines. The results obtained are often far more val- 
uable than the public realizes or expects. At the same 
time, the definiteness of these results, because of the 
facts already outlined, are far inferior to those ob- 
tained by the laboratory examination of infected per- 
sons — in brief, the information obtained by the labora- 
tory from the examination of " samples " usually re- 
quires elucidation and explanation in the light of all 
sorts of other information, sociological, meteorological, 
topographical, geological, etc. Considered thus, the 
laboratory work is nearly invaluable, but, taken by 
itself, almost as nearly worthless. 

The happy ignorance displayed by those who think 
that an analysis of water, or milk, or food, even the 
most thorough, can in itself and by itself give useful 
sanitary information is equalled only by the joyful con- 
fidence of the southern darkey in a rabbit's foot. 2 

The true position of the laboratory in the co-ordina- 
tion of public health workers which will rule in future 
organization, has been achieved but seldom. 

2 The British Medical Association at its annual meeting, held 
1912, passed the following resolution: "That this con-joint 
meeting of the sections of State Medicine and Bacteriology unani- 
mously desires strongly to urge that no opinion as to the quality 
of a water for dietetic purposes should be arrived at on bac- 
teriological evidence without a local and topographical inspection 
of the sources of the supply made by a competent observer." 



130 THE NEW PUBLIC HEALTH 

The Public Health laboratory man of to-day has 
ceased to be the leader in public health endeavor which 
he once was, partly because he has been swamped with 
routine work in the lines he has himself developed, but 
chiefly because, being a laboratory man, the very nature 
of his work has kept him indoors, out of and apart from 
the stirring fields of human life in being. Perfect 
enough in his own technic, he has perforce lost touch 
with all but his own work, and other lines of public 
health, more closely involved with the outer world, have 
passed ahead of his. 

The laboratory man of the future will get out into 
the actual daily lives of the people and communities he 
serves. He will know outside conditions as well as 
those in the laboratory. He will work more closely 
with the engineer and the epidemiologist. He has his 
own place which they can fill no more than he can fill 
theirs, but he must understand their work, and they his, 
much better than at present. 

Moreover, the engineer and the epidemiologist suffer 
from the present disassociation of the laboratory quite 
as much as does the laboratory man himself. Field 
work moves lamely, oftentimes, from lack of laboratory 
knowledge, just as laboratory work is oftentimes inert 
from lack of field knowledge. During the last few 
years the frequent transfer of laboratory men into the 
field work of epidemiology and engineering has evolved 
a set of men who recognize this fully. But it is not by 



COMMUNITY DEFENSE 131 

transferring laboratory men to other fields that the 
laboratory can be developed. It is by putting the lab- 
oratory itself into the field — and only so — that this 
can be accomplished. 

In field work, and in research, so much neglected of 
late, the laboratory man will find his future, and he will 
not deal solely, as at present, with infectious diseases. 
True, the venereal diseases must be added to the present 
list of those for which routine laboratory facilities are 
provided. But some non-infectious diseases may be- 
come preventable diseases, if their causes are discovered, 
and the Public Health laboratory of the future, acting 
in conjunction with the physiologist and the pathologist, 
may find therein usefulnesses now undreamed of. Fi- 
nally, as we slowly learn the true personal hygiene of 
food, clothing, sleep, exercise, etc., the Public Health 
laboratory will take its share in the greatest, but least 
developed, of all Public Health procedures, namely, the 
physical advancement of the race. 

SUMMARY 

The Public Health laboratory finds its chief functions 
to-day in the detection of infectious persons (sources), 
and in the identification of infected things (routes), as 
means to the end of abolishing those sources and block- 
ing those routes. The average public health laboratory 
has been swamped with routine, cribbed, cabined, and 
confined until useful research has almost died out and 



132 THE NEW PUBLIC HEALTH 

real knowledge of outside conditions has been lost. The 
engineer and the epidemiologist have progressed fast 
and far by active contact with the needs of the outside 
world, and the laboratory can attain its proper future 
only by like development. 



CHAPTER XII 
COMMUNITY DEFENSE 

THE PUBLIC HEALTH STATISTICIAN 

In the development of the new public health princi- 
ples, the laboratory came first. It dealt with the causes 
of disease at first hand, as well as with their sources and 
their routes of transmission. On laboratory findings 
all modern public health is based, although in practice 
the laboratory is necessarily limited, for daily service, 
to those diseases the causes of which are known. 

But in its earlier work, the laboratory, inheriting 
somewhat the environmental teachings of the older 
school, paid more attention to routes than it did to 
sources, especially to the routes constituted by (a) water 
and (b) general surroundings. This focused attention 
on (a) sanitary engineering and (b) disinfection. It 
was in the earlier laboratory period that the sanitary 
engineer and the disinfector developed highly. It is 
true that the engineer deals almost solely as yet with 
but one route, water ; and that therefore his efforts neces- 
sarily relate almost solely to the intestinal infections, 
mainly to typhoid fever. Nevertheless, so valuable 
were his services in reducing this disease, that engineer- 

133 



134 THE NEW PUBLIC HEALTH 

ing work was hailed at one time as the solution of all 
public health questions. Now the epidemiologist leads 
the van, because he deals not with some routes, of some 
infectious diseases, but with all sources of all infectious 
diseases. 

STATISTICS AS THEY WILL BE 

But, through the work of the laboratory man, the 
engineer, and the epidemiologist, has for long been heard 
a still, small voice, offering a framework to bind them 
all together — to give coherence, correlation, and pro- 
portion — to outline the future, as well as to record the 
past, and, above all, to direct the present. This was the 
voice of the vital statistician. Much abused, laughed 
at, neglected, he is, or will be, guide, map-maker, intelli- 
gence department, all in one ; he is, or will be, like the 
cost-of-production scientific manager of modern busi- 
ness, " the most indispensable man on the staff." 

True, his professional ancestors were helpless old gen- 
tlemen, raising their feeble voices in very feeble chants. 
A dry-as-dust historian of the wars of ancient Greece 
could lend more aid to a modern football team than the 
old-time statistician furnished to public health en- 
deavors. Even now the new vital statistician is scarcely 
yet full-born. Hardly a health department now in ex- 
istence collects in full or uses to full advantage one- 
tenth the information that it really needs. (A notable 
exception should be recorded here, the Richmond (Va.) 
Health Department under E. C. Levy.) The labora- 



COMMUNITY DEFENSE 135 

tory man has made some good statistics in his own field ; 
so has the sanitary engineer — sometimes, alas, not 
wisely, but too well ; the epidemiologist, also, from sheer 
necessity : but the new vital statistician has only begun 
to move. When he does move, fully equipped, alert, he 
will systematize, organize, and use the rich data so far 
largely wasted, this very life-blood of public health en- 
deavor, accurate, complete information concerning the 
way humanity reacts to human ills. Internal public 
health organization has been like the old-time factory, 
full of good workmen, but each working only his own 
line, with no one person knowing much about the busi- 
ness as a whole. At the end of the year the business, 
drifting along, perhaps showed a doubtful profit, per- 
haps a loss, but so long as bills and wages were somehow 
paid, who cared? Public health requires exactly the 
kind of man who has changed the face of business in the 
last fifteen years, a man who understands all parts of 
it, but does none himself; a man who knows costs in 
each department in proportion to production, and where 
to cut cost, increase production, save time, unnecessary 
work, and waste in general ; alas, in health departments, 
a man to stop the one-half, now done uselessly in wholly 
wrong directions and to force development of the other 
half, now much neglected or left undone completely. 

It is the vital statistician who must do this: collect 
the facts and set them forth inexorably, with mathe- 
matical precision. When it is done, our health depart- 
ments will no longer use up $30,000 for garbage, with 



136 THE NEW PUBLIC HEALTH 

the probability that not a single life will be saved 
thereby, while spending $12,000 on all other health de- 
partment efforts combined. Nor will a health depart- 
ment spend for terminal disinfection one-tenth its an- 
nual appropriation, to save no lives at all, 1 while using 
but one-fiftieth its appropriation for tuberculosis, which 
kills five times as many people as all the diseases usually 
" disinfected " put together. 

It will be said : " You are confusing vital statistics 
with health department finance ; vital statistics deal with 
deaths, not money." Exactly — and that is just ex- 
actly what is wrong with them. Vital statistics are 
now, in short, not vital; they deal with Death, not Life, 
with the " finished product " only of our slack, slipshod 
methods. They ought to deal, not merely with dead 
bodies, but who they, living, were, and why and how 
they died, and above all with why they were not saved. 
Suppose the factory manager knew at the end of the 
year merely his total product ! Suppose that even this 
piece of information related, not to the way business 
went last year, but to the way it went five years before. 
" Historical records, and mighty poor at that," a mod- 
ern public health man said in bitter scorn of the sta- 
tistics of a neighboring State. The modern scientific 
manager must know not merely the total product, though 
he must know that, and to the minute, not to five years 

3-In tuberculosis, where terminal disinfection would be valu- 
able it is not often done. — J. A. P. H. A., April, 1913, p. 311, 
M. N. Baker. 



COMMUNITY DEFENSE 137 

before; he must know also all about the product, the 
kind, the quality, the cost, and why it is not better for 
the price. The modern vital statistician must know 
not only deaths, but why the health department is not 
stopping them ; what its funds are ; how they are spent 
or wasted ; what work is being done ; how much of value 
each division does ; and all to the one end of saving life, 
not to the end of stopping nuisances, removing garbage, 
or cleaning streets — all admirable ends no doubt, but 
not life-saving ends. 

But, it will be said, " Very well, but you are wrong 
in stating that Vital Statistics deal with Deaths. They 
deal with more than Deaths — they deal with Births 
and Marriages and contagious diseases also." " Yes, 
nominally ; but to what useful end for public health % " 2 

" Birth records quite often affect inheritance of 
estates in later years." True, and very useful to the 
inheritor they are when the time comes, but what has 
that got to do with saving life now ? Marriage records 
also are invaluable in their own way, but they do not 
reduce tuberculosis one-tenth of a tenth per cent. Con- 
tagious disease reports, then ? Surely they are impor- 
tant ? Yes, but not as they are, too often, now collected. 
Misleading information is sometimes worse than none at 
all. 

2 Birth records, if they led to immediate investigation to see 
that the child was cared for properly, would be true public health 
data. 



138 THE NEW PUBLIC HEALTH 



STATISTICS AS THEY ARE 

The best way to show what public health vital statis- 
tics as they are to-day mean, or do not mean, is to give 
the story, true to life, as any one who knows will quickly 
see, of the very basis of such statistics, the actual facts 
as they occur amongst the people. 

Mrs. Anybody says to Mr. Ditto : " I am afraid 
Tommy has scarlet fever ; I think he must have caught 
it when he was in the city." " Call Dr. A." " Yes, 
but they say he will report it, if it is scarlet fever. I'm 
nearly wild now with work. When the children are at 
school all day I manage somehow ; with you and the chil- 
dren quarantined at home for a month I should go in- 
sane. I'll call Dr. B. ; they say he never reports any- 
thing. I'll tell the neighbors it is scarlet rash. That's 
not a lie. It's a rash, and it certainly is scarlet. I'll 
let the children go to school, but I'll keep every one 
away from Tommy. I'd hate to think any other child 
got it from our children, but I guess that will be all 
right. Tommy is not very sick. Don't go telling any 
one he is sick. I'll tell the children not to, either. We 
don't want to have the milkman or the grocer afraid to 
call." 

So Mrs. Anybody plans, and so it is carried out. But 
her heart is bigger than her head, and her plans go 
strangely awry. 

She puts Tommy in a room by himself and runs over 
to a neighbor's for an egg or a cup of flour. When she 



COMMUNITY DEFENSE 139 

comes back tlie other children are lined up in Tommy's 
room, solemnly inspecting the rash he proudly demon- 
strates to them. Next morning Tommy is " real sick/' 
and after breakfast the mother puts up the other chil- 
dren's school lunches alternately with running in to 
Tommy's room to give him water or to hold the basin 
while he vomits or just to kiss and soothe him. 

Poor, loving, hard-working mother! She has done 
this same through all the ages, this taking of infected 
discharges from the sick child, on her hands, to be put 
later in the other children's food. No, she won't kiss 
them good-bye; she has been kissing Tommy; that is, 
she won't kiss any but the smallest one, who looks near- 
est to crying. . She wipes that one's mouth with her 
apron before she kisses it — she does not wipe her own! 
Not that wiping either matters, for Tommy's mouth 
discharges are already in the lunch the little one 
marches out with, under its arm. 

About 10 a. m., the empty house and the wailing 
child get on the mother's nerves. So she calls in a 
neighbor. " Tommy's sick. I want to go to the store 
to telephone the doctor. It's only scarlet rash. I won't 
be gone more than a minute, but I'm afraid he'll get 
out of bed or something. Will you keep an eye on 
him?" 

The neighbor comes in, the baby on her arm, for is it 
not scarlet rash? But prudence strikes her suddenly, 
and she sets the baby on the floor before she peeks in at 
Tommy. " Hullo!" " Hullo, Mrs. Neighbor!" a 



140 THE NEW PUBLIC HEALTH 

feeble little voice replies. She steps in further, leav- 
ing the door open to keep an eye on baby. " Well, 
Tommy, how do yon feel ? " " Not very well," and he 
begins to vomit. She snatches a basin, holds his head, 
and in a moment surrenders him to his mother, and 
then takes her baby hurriedly home. A speck of vomit- 
spray has hit her hand. She did not notice it. The 
baby's fingers rest on it a moment, before it is dry; a 
minute later the baby sucks that finger. At home she 
sets the baby down and, conscience-smitten, changes her 
dress {she does not wash her hands!) and thereafter 
feels all right again because she thinks that now she 
can't give it to any one, even if it is scarlet fever; be- 
sides, the doctor said it was scarlet rash. 

Meantime, Mr. Anybody, summoned by his wife, 
hurries home in terror, finds Tommy still quite alive, 
growls, fusses, brings in some wood, pumps a little 
water, and then steps into Tommy's room, " just inside 
the door for a minute," before going down-town again. 
Tommy, with feverish, flushed face and heavy eyes 
under his tousled hair, calls feebly, " My daddy, my 
daddy " ; and, of course, Mr. Anybody steps to his bed- 
side to pat his head and kiss him, before hurrying back 
to business. 

That night Tommy is worse ; sorrow is on the family 
in earnest. Next morning Tommy is much better ; the 
prayers and tears of the night before are forgotten ; the 
mother, weary but joyful, lets the other children in to 
see him; " just for a minute now, but, anyway, he is so 



COMMUNITY DEFENSE 141 

much better/' and they all race out to school, shouting 
and laughing. 

About five days later, Susan, the youngest, is not 
feeling very well towards evening, vomits during the 
night, is delirious next morning, with sore throat, 
swollen neck, and rash ; and Dr. B. comes again. Seri- 
ous measures are taken. The other children, in tears, 
are spirited away to a cousin's house to stay lest they 
should get it, and because the mother can't stand the 
strain of nursing the sick and caring for the well also. 

Tommy has had it mildly, and by this time is up and 
about, wandering disconsolately through the empty 
house. To all inquirers the mother bravely maintains 
that Susan has only the scarlet rash and tells them 
Tommy will go back to school in a day or two. " I 
just sent the other children away because they were so 
noisy," she explains guiltily, wishing very earnestly 
that it was really so. 

Next day Susan is better. (I am writing this — 
and therefore I make it thus. In real life, poor little 
Susan often dies, instead.) Every one is cheerful 
again. Tommy is sent, very unobtrusively, to school 
because " he mopes at home, without a soul to play 
with." He is beginning to peel, and, in a day or two, is 
in much demand amongst his schoolmates, presenting 
them with souvenirs of flakes of skin they treasure as 
curiosities. Not that these scales do harm, despite the 
old beliefs. It is not the peeling, which everybody 
sees, that does the mischief, but the unnoticed slightly 



142 THE NEW PUBLIC HEALTH 

red sore throat that Tommy carries with him, and from 
which he infects his hands (and every one he touches) 
and shoots out infection in his mouth-spray as he chants 
his lesson, or whispers across the aisle, or sings in class. 

And so the old, old story works itself out inexorably. 
One of the other children, staying at the cousin's, de- 
velops a slight sore throat. Were there an epidemiolo- 
gist at hand, posted on the history of the child, to scan 
the enlarged papillae of the tongue, note the large 
glands, and see the filmy membrane on the tonsils, the 
case would be recognized as scarlet fever, sine erup- 
tions i.e., without a rash. But as it is " it's only a 
sore throat." No physician sees her, because the cousin 
argues thus : " If it were my child, I'd have in Dr. 
A., but Mrs. Anybody wouldn't thank me for running 
up another bill here, unless the child is really ill ; she's 
having Dr. B. now, for Susan, twice a day. I'll wait a 
day or two, anyway." 

The sore throat heals, and the cousin feels she made 
a good judgment. But meantime the sore-throat girl 
has been sleeping with the cousin's little girl, and she 
develops it, too, but it also passes off. Then a week 
later, the cousin's little girl's school-chum, in a different 
school from Tommy's, has scarlet fever proper. Dr. A. 
attends, and reports it. The Health Department puts 
a placard up; the children are kept out of school; the 
father is kept at home; the whole population turns its 
eyes on, that family and wonders where they got it. 
The village wiseacres, over the village bar, remind each 



COMMUNITY DEFENSE 143 

other of the slough behind the house, or that the gar- 
bage from the family was never removed all summer. 
They say the well is shallow, " nothing but surface 
water," or the house is damp, or too much shut-in by 
trees, or any other fatuous foolishness that enters their 
empty heads. The mayor gives out a statement to 
" allay popular excitement." He brands as malicious 
all statements that scarlet fever is rampant. There is 
but one " sporadic case," originating no one knows how. 
It is carefully quarantined, and " the Health Depart- 
ment believes the outbreak is well in hand and prac- 
tically stamped out." The Women's Club demands the 
fumigation of the schools; and the epidemiologist, if 
only he were present, would gaze reflectively at Tommy's 
slightly red throat, and gnash his teeth, and swear. 3 
Poor Dr. A. who only did his duty, is blamed for all 
the trouble; and Dr. B. keeps mum. When, pres- 
ently, Dr. C. is called to one of Tommy's schoolmates, he 
hesitates. He has not seen much scarlet fever, and he 
thinks, " perhaps it is scarlet rash — whatever that 
may be." He attends the child two or three days, and 
then he begins to ponder whether or not he had best put 
the responsibility on the Board of Health; so at last 
he calls up Dr. D., the Health Officer. But Dr. D. has 
troubles of his own. " Do you say it is scarlet fever ? " 

s Editor's Note. — We regret the epidemiologist should do this, 
but we propose to give the facts, no matter whom they hit. Be- 
sides, we do not blame the epidemiologist much under the cir- 
cumstances. 



144 THE NEW PUBLIC HEALTH 

" Well, I don't know. I want you to go and see." The 
H. O. is perplexed. He does not want the reputation 
of finding a second case, after the Mayor has stated that 
there is only one ; so he tells Dr. C. : " If you report it, 
I'll placard the house, but I don't want you to report 
it, if you are not sure." At this Dr. C. waits a day or 
two more, but finally reports it. Meantime a week of 
association of the other children with the sick one has 
elapsed, because Dr. 0. did not quite know the finer 
points in recognizing mild scarlet fever early. 

By this time, between the unconscious activities of 
Tommy and Susan, who are back at school, well oiled 
by Dr. B.'s advice, to keep the scales from showing, and 
of Susan's sister and the cousin's little girl (none of 
them recognized officially as scarlet fever), some twenty 
or thirty children in the two schools have been infected. 
Some of the pupils have had scarlet fever before and so 
escape this time. In others the disease is mild and 
passes unnoticed. In others " scarlet rash " develops. 
But several develop frank scarlet fever, not to be denied 
even by Dr. B. who, to give him credit, has begun " to 
get a little scared," and so reports one or two well- 
marked cases to relieve his conscience. Two or three 
deaths occur, and then the schools are closed, but not 
the Sunday schools, or churches, or private sociables, 
or moving pictures, and so it drifts. 

Now, see how all this affects vital statistics. The 
Health Department, in its annual statement, gives as 
the first case that school chum of the cousin's little girl. 



COMMUNITY DEFENSE 145 

We know that there were four cases before that — 
Tommy and Susan, and Susan's sister, and the cousin's 
little girl — but these do not go down upon the books 
at all. The Health Department adds thirteen more 
cases; that is, all those cases attended by Dr. A., faith- 
ful, conscientious man; about half of Dr. B.'s cases, 
those he had after he " got scared " ; and some of Dr. 
C.'s, but only those he was absolutely certain of, not 
knowing scarlet fever very well. Dr. D. had no cases, 
because, being health officer, the mothers felt that he 
would have to report them, and so did not call him. 

The fact is, that any epidemiologist would find that 
there were forty cases, but the books show fourteen. 

Then consider the deaths. Two were reported prop- 
erly as due to scarlet fever. But one of Dr. B.'s, really 
scarlet fever, not quarantined while ill, is reported 
" acute Bright's disease," because the doctor dare not 
say it died of scarlet fever after treating it a month 
without reporting it. It is quite true the child had 
Bright's disease, but it had Bright's disease because it 
had scarlet fever. Another dies of meningitis, due to 
middle-ear infection, the result of scarlet fever, but 
being meningitis, this death also goes in a different col- 
umn. The more or less spoiled ears and the more or 
less spoiled kidneys of twenty other children who re- 
covered never are recorded on the books at all. 

Hence, fourteen cases where there should be forty; 
and two deaths, where there were really four, are re- 
corded officially as scarlet fever. 



146 THE NEW PUBLIC HEALTH 

This instance exemplifies practically the whole situa- 
tion; mild, unrecognized, and concealed cases; cases to 
which physicians are not called at all; mistaken diag- 
noses ; a superficial report covering a few of the severer 
cases only; death reports correct so far as they go, but 
not showing the relation of the death to the preceding 
disease. This occurs, not occasionally, in a few com- 
munities, with scarlet fever only, but, almost every time, 
in almost every community, with almost every one of 
the infectious diseases. 

The returns from Anybodyville are small in number, 
it is true ; but multiply these by all the similar commu- 
nities which make similar returns. Anybodyville re- 
ports two deaths and fourteen cases from scarlet fever, 
where there were four deaths and forty cases. This is 
" only " two deaths and twenty-six cases wrong. But if 
one thousand communities report similarly, our statis- 
tics are wrong two thousand deaths and twenty-six 
thousand cases. 

Moreover, see how the percentages are twisted and 
tangled. Two deaths from fourteen cases is about 14 
per cent. Two deaths from forty cases is 5 per cent. 
Four deaths from fourteen cases is 28 per cent. Four 
deaths from forty cases is 10 per cent. When we re- 
member that the number of cases of scarlet fever, and 
of other diseases, is often calculated from the deaths by 
the percentage which the deaths usually are of the cases, 
we find that we can calculate the cases from one hundred 
deaths of scarlet fever (on the above returns) as seven 



COMMUNITY DEFENSE 147 

hundred, two thousand, three hundred and fifty, or one 
thousand — how very valuable ! 

SUMMAJRY 

The vital statistician of the future will be the scien- 
tific manager of a business department, for, through the 
epidemiologist working in the field, he will know where 
the diseases are, not where they were, and he will know 
which disease demands the most attention. He will 
know also what resources, in men and money, the health 
department has, with which to fight its battles. The 
correlation of these two factors has seldom been achieved, 
although in life insurance it has long been known that 
their inter-relations were the absolute sine qua non of 
success. Any business man's first step in reorganizing 
public health for actual service would necessarily be 
(a) to determine what requires to be done; (b) to de- 
termine what there is to do it with. The maximum 
required returns from the minimum necessary expendi- 
ture should be the only motto. To secure this informa- 
tion, no one but a statistician knowing statistics, but 
knowing men and things as well as figures, can succeed. 
To confine his work to deaths, even to cases, from 
preventable diseases, is to study output only, with no 
regard to income. To study income, as is so 
widely done, without regard to whether that income is 
spent to achieve lessening of disease and death, or 
merely for nuisances or smoke inspection, is simple 
madness. 



CHAPTER XIII 
ADMINISTRATION 

The administrator of public health is confronted as 
we all are in every line of life by the necessity for dis- 
criminating ^Esthetics or what we would like to have, 
Hygienics or what we need, and Economics or what we 
can actually secure. 

Too often the administrator, tempted by the desire to 
please, or yielding to the pressure of demands made by 
the unknowing, or even himself suffering from confusion 
of mind as to the relations of cause and effect in public 
health work, has devoted his department to such aesthet- 
ics as might be within his grasp, neglecting entirely or 
largely the truly hygienic measures he might have un- 
dertaken. Quite generally, out of date laws, ordi- 
nances devised by the most ignorant of lawmakers, have 
compelled the most wise administrator to subordinate 
measures he knew to be valuable to those he knew to be 
useless for the suppression of disease and death. Thus 
it comes about that many health departments are loaded 
down with expenditures in money, men and time, for 
non-health purposes which, good in themselves, or at 
least harmless, absorb the forces which might be de- 
voted to directly improving health or to preventing dis- 

148 



ADMINISTRATION 149 

ease. There are those who say, " If the object is a 
good one, why object to the Health Department doing 
it ? — does it matter to the citizen whether or not the 
garbage is removed by the Health Department or the 
Street Department so long as it is removed ? " This 
argument would be passable, if all health departments 
had unlimited money and were manned by experts in 
every line of municipal care. Then there would be no 
administrative objection to handing over, not garbage 
only but charities and corrections and the customs col- 
lection, inland revenue and conduct of the schools to 
health departments. As it is, however, with inade- 
quate means for even their proper functions, and with 
experts trained in medical lines or cognate subjects, the 
health department supervising utilities of this kind is 
a splendid example of carefully constructing a razor, 
and then needlessly using it as an axe. 

But there is a much deeper and more serious error in 
such division of health department work, the great error 
in recent public health administration, the error of edu- 
cating the public, not by words, but deeds, to the con- 
ception that aesthetics, the miscellaneous methods of 
municipal housekeeping, the cleanliness of externals, 
the neatness and promptness of the garbage and ash 
collections, are the essential weapons against disease. 
As well say that the ordinary order and cleanliness of 
the wellkept home creates it a fit hospital for contagious 
diseases. 

Many a health department now standing high in the 



150 THE NEW PUBLIC HEALTH 

estimation of the citizens and gaining praise in all direc- 
tions from those who see its spectacular operations for 
cleanliness, smoke prevention, etc., is really not only a 
total failure in suppressing disease (except sometimes 
in suppressing the fact of its existence) but is actually 
misleading the public and building up false ideals which 
ultimately damage the community and the race, causing 
loss of life and money immensely in excess of the com- 
fort or economy secured by such municipal cleanliness. 
Municipal cleanliness is excellent in itself — it is the 
substitution of municipal cleanliness for the real dis- 
ease prevention that we deplore. 

The ideal health department of to-day organized to 
suppress disease and death, not to clean streets or to 
fuss about the plumbing, need at the present time con- 
sist of but five or six technical divisions corresponding 
with the basic essentials, man and his surroundings. 
These are the Epidemiological Division, dealing di- 
rectly with the individual, sick or well; primarily for 
the discovery of the infected persons, secondarily for the 
control and elimination of the sociological conditions 
contributing to infection. 

For the surroundings of man is needed a Sanitary 
Engineering Division dealing with all the essentials of 
construction and operation of public or private utilities 
which bear upon the promotion of health or the preven- 
tion of disease and death, i.e., for the control of the 
physical sources and elimination of the physical routes 
of transfer of disease. 



ADMINISTRATION 151 

For the bookkeeping of this combination an alert ac- 
tive Vital Statistics Division is essential — not for the 
bookkeeping of dollars and cents but of human lives and 
health. 

A Laboratory Division is required, to apply to the 
activities of the epidemiologist and the sanitary en- 
gineer the most advanced of chemical and bacteriological 
work. This division should be, like the others, fully 
equipped in men and money for every known form of 
investigation into the preventable diseases, and the anal- 
ysis of anything which may be useful to the prevention 
of disease, especially for the analysis of sewage, water, 
milk and other foods, drugs, poisons, etc., in brief, for 
the analysis of man and of those surroundings of man 
which affect him disastrously, or favorably. 

A figure now new in health department activities 
should be a permanent feature in the future, although 
at the present time the work he could do would be 
largely investigative and advisory, i.e., a trained Physi- 
ologist, devoting himself to the study of physiology as it 
relates to hygiene, i.e., to the attainment of physical 
perfection and efficiency, with comfort; and the main- 
taining of the same through a long life. The division 
which he heads should be equipped for every form of 
investigation into food values, labor conditions, espe- 
cially in factories and in schools (the universal fac- 
tories which all must enter) and should devote itself 
wholly to studies developing ultimately to the place 
where actual legal enforcement of valuable regulations 



152 THE NEW PUBLIC HEALTH 

relating to hygienic conditions may be made, not lim- 
ited to mere physical surroundings but also including 
hours of labor, housing and many other problems now 
largely drifting. 

In those communities where medical school inspec- 
tion is under boards of health this physiological division 
might well directly control it. When under well 
equipped school boards the actual operations of the 
medical inspection may well be conducted in close co- 
operation with this division. 

Of the non-technical divisions a most important one 
is that which engages itself with Publicity. Although 
usually best managed as a subdivision of the adminis- 
trative mechanism, this division should be regarded as 
equally important with any other and should be in the 
closest touch with all of them, keeping records of and 
publishing promptly the work of each department in an 
acceptable form ; explaining the principles and aims of 
the whole in each of the operations it undertakes; and 
posting the public on the actual conditions found, the 
problems they present, the remedies proposed and the 
results of remedial operations. This division might 
well use lectures and similar methods as well as news- 
papers and its great keynote should be — must be — 
the truth, the whole truth, and nothing but the truth. 

The Administrative Division should itself be the 
center of the whole mechanism, seeing with the eyes and 
ears of all the other divisions, planning, correlating, 
directing, demanding returns for all monies spent and 



ADMINISTKATION 153 

shifting the weight of a large General Fund from divi- 
sion to division as the needs vary. The finance sub- 
division should be equipped with expert accountants 
who are well posted on the needs as well as the 
mere outgo of each division. Administration is a 
business as well as an art in any large operation, 
whatever its purpose. But in public health work it is 
a business and an art which is supposed to be and there- 
fore should be, energized and directed to the general 
physical welfare of mankind; enlightened with a fine 
appreciation of relative values ; and guided by the great 
general's discrimination between the essential and the 
non-essential, the things that win as distinguished from 
the things that merely seem to ; the things that threaten 
in appearance only, as distinguished from the appar- 
ently innocent things that really mean great mischief. 
The head of the administration should be unham- 
pered by any Board of Strategy. The chiefs of his own 
divisions, picked properly to begin with, should form 
his best council, and he should seldom need other. 
Political exigencies should control him no more than 
they control the military officer in the face of the enemy. 
The Board of Health of to-day is often a mere anachro- 
nism, built up when there were no experts, with the 
hope that, all being blind, combining one with another 
would manufacture sight between them. Now that 
men really versed in public health can be secured, noth- 
ing is gained by placing a merely official board in actual 
control, for if composed, as many boards may now be, of 



154 THE NEW PUBLIC HEALTH 

experts, they tend to take the place of a single executive ; 
while if composed, as they usually are in practice, of 
inexpert laymen, or worse, physicians inexpert in public 
health, but who are nevertheless under the supposed halo 
of a medical degree, they do more harm than good. 
A very level-headed board of very just, far seeing, men 
will sometimes be found whose advice in conference is 
of real value to the administrative head 1 but these are 
the exception, and many Boards are merely excuses for 
political control and diversion to spectacular ends of 
monies which should be expended on the objects for 
which they were appropriated, i.e., for public health 
and the diminution of disease and death. Such an 
ideal Health Department, in close touch with every 
agency dealing with social or physical improvement, 
will be in close touch with the medical profession. It 
should not be burdened with general hospital manage- 
ment nor as a rule with the management even of a con- 
tagious disease hospital : but it should control the situa- 
tion completely so far as such agencies have to do with 
the spread or prevention of spread of all infections. 
In the hospitals as in the schools and factories its rule 
in this respect, should be quite absolute. The Admin- 
istrative Division needs a law subdivision and usually 
a police subdivision also. The reporting of contagious 
diseases by physicians should be enforced, but with a 
properly conducted Epidemiological division, it should 

i It has been the writer's good fortune to work under such 
Boards in both Minnesota and London. 



ADMINISTRATION" 155 

be rather the rule for the Health Department to dis- 
cover and report cases to the Medical profession for 
treatment than that the medical profession should re- 
port infection to the Health Department. Indeed until 
the existing status is reversed, until Health Depart- 
ments know more of the whereabouts of infectious per- 
sons than the whole medical profession can tell them, 
the abolition of infections will remain a dream of the 
future. 

•We have spent many years blaming the medical pro- 
fession for laxity in reporting, without stopping to 
think that if every medical man reported correctly every 
infection that he sees however trivial, still infection 
would be continued through those cases that call no 
physician, and through infected persons who are not 
sick. Until Health Departments do more — much 
more — than perfunctorily placard only reported cases, 
there is no inducement to physicians to report their 
cases ; and until Health Departments are equipped with 
means and insight to provide properly in all respects 
for the infected persons thus cut off from their usual 
associations and operations, such segregation is an in- 
justice that the public will continue to resent. 

So long as governments permit infection to go un- 
checked, relying footlessly on physicians' reports alone, 
the persons who unwittingly become infected should 
have rights in suits of damages against such govern- 
ments. This has been the enlightened ruling with re- 
gard to typhoid fever contracted from a public water 



156 THE NEW PUBLIC HEALTH 

supply. There is no reason why it should not be ex- 
tended to every form of infection however contracted. 

SUMMARY 

The Health Department of the future will be a busi- 
ness department for the suppression of disease and 
death and the promotion of general high health, not as 
at present a pseudo-charitable institution for the con- 
duct of a jumble of activities, a muddle of municipal 
cleansing and aesthetics. 

The administrative head will be an expert, not a 
political exigency; and his lieutenants will be men of 
training as deep and broad as his own, each in their 
specialties. These will be epidemiology, vital statis- 
tics, sanitary engineering, bacteriology and chemistry: 
each organized on the broadest basis for actual efficient 
accomplishment of the ends of public health. The ad- 
ministrative division, well equipped for financial super- 
vision and executive direction of the whole, will never- 
theless be devoted to the one end of accomplishing re- 
sults; and will include as an important feature a pub- 
licity bureau or division ; while as the next development 
of the future, a trained physiologist to study the ques- 
tions of hygienics as applied to the community may 
well be added. 

The sanitary inspections, back yard cleanings, street 
sweepings, smoke preventions, weed cuttings, removal of 
dead animals, garbage disposals and other like physical 
functions of a municipality will be relegated to the 



ADMINISTRATION 157 

Public Works or Street Departments, relieving the 
Health department of physical burdens and setting 
them free for their true sociological work with human 
beings. 

This scheme is not by any means for big cities only. 
The smaller cities and towns and rural districts must be 
combined into populations of 20,000; or even less in 
sparsely settled areas. For each of these a similar de- 
partment should exist. The present reproach that half 
the population, i.e., that half residing in the country, 
is practically without public health agencies, must be 
removed and every citizen treated equally wherever he 
lives. This is not mere abstract justice but also a real 
need. 

The realization that infection moves back and forth 
from urban to rural districts and vice versa should 
give to all the clearest understanding that disease in 
one depends upon disease existing in the other as much 
as in itself and neither city nor country can free itself 
alone but both must act together. The summer col- 
onies of city people in the country, the constant visits 
of country people to the cities, the growing interchange 
in every way, have done away forever with distinctions 
from the public health standpoint. No government 
that fails to recognize this can succeed in public health 
campaigns. 



OHAPTEE XIV 
COMMUNITY DEFENSE APPLIED 

TUBERCULOSIS ITT GENERAL 

Previous chapters have outlined the general prin- 
ciples which govern modern public health efforts. The 
present chapter will show the specific applications of 
these principles to one specific infectious disease, 
namely, tuberculosis. This disease is selected because 
the same principles that apply to all other infectious 
diseases apply to it and because it is the most important 
of all the diseases now recognized as really preventable, 
with the exception of the venereal diseases. 

Tuberculosis, in all forms, is due to the growth, some- 
where in the body, of a certain germ, exactly as diph- 
theria and typhoid are due to the growth, in the body, 
of certain germs. There are many very definite indi- 
vidual differences, in the size, shape, manner of growth, 
etc., of the three different germs of these three different 
diseases, and these differences make it perfectly possible 
to distinguish each germ from the others, just as any 
farmer can distinguish oats, corn, and potatoes from 
each other. 

But just as there are different varieties of potatoes, 

158 



COMMUNITY DEFENSE APPLIED 159 

so there are at least two varieties of tuberculosis germs 
which affect human beings. Ohe variety is what is 
known as the human tuberculosis germ proper. The 
other is found chiefly in cattle and is therefore called 
the cattle tuberculosis germ (the bovine tuberculosis 
germ), and this name is given to this variety even when 
it is found in the human, as it sometimes is. 

HUMAJST TUBERCULOSIS 

One of the most important differences that the germs 
of human tuberculosis, of diphtheria, and of typhoid 
fever show amongst themselves is not a difference in 
size, shape, etc., but in the parts of the body each selects. 
Thus the diphtheria germ flourishes chiefly in the nose 
and throat; the typhoid germ flourishes chiefly in the 
intestine and perhaps in the blood; while the human 
tuberculosis germ will flourish almost anywhere in the 
body, glands, bones, joints, intestine, kidney, brain, 
lungs. This selection is no mere accident, although we 
do not know how it comes about. All three germs enter 
the body chiefly by the mouth, conveyed thereto chiefly 
by the hands, but also more or less through food and 
milk, and, in the case of typhoid fever, through water 
and flies. On entering the mouth, all three germs, 
which are of course far too small to taste or feel, are 
swallowed in the food, milk, etc., in which they happen 
to be present, or merely in the saliva, if, as is most usual, 
they reach the mouth directly or indirectly from the 
fingers. Once swallowed, all three pass into the stom- 



160 THE NEW PUBLIC HEALTH 

ach, where many are killed by the acid there present, 
the survivors, if any, passing on into the intestine. On 
this journey from mouth to intestine, some are left, of 
course, by the wayside, stranded on the tonsils, throat, 
gullet, etc. Here at once is shown their respective 
peculiarities. Of all the diphtheria germs that are thus 
swallowed, practically only those that are stranded in 
the throat will flourish; those diphtheria germs which 
pass on into the stomach or intestine are destroyed or 
pass out harmlessly. On the other hand, typhoid germs, 
if stranded on the throat, do not flourish there, nor do 
those which reach the stomach flourish in that organ. 
It is only those typhoid germs which survive the jour- 
ney until the intestine is entered that can succeed in pro- 
ducing typhoid fever. The human tuberculosis germ 
has a still longer road to go. ISTot only must it pass 
mouth, stomach, and intestine ; also it must be absorbed 
from the intestine into the blood, as the food is ; but it 
does not grow in the blood. The blood is only a river, 
by which it can be carried to a favorable developing 
ground. We do not know at all why human tubercu- 
losis germs, entering the blood thus, should finally settle 
and grow in a joint in one person, in a lung in another, 
in a kidney or a gland or a bone in another. However, 
this is the way in which these different forms of human 
tuberculosis develop. The old idea that human tuber- 
culosis of the lung (consumption) is contracted chiefly 
by breathing the germs directly into the lungs has been 
definitely upset. The lungs are infected from the 



COMMUNITY DEFENSE APPLIED 161 

blood-stream chiefly, just as are the other internal or- 
gans, bones, and joints. 

Another and, from the public health standpoint, an 
even more important difference exists. Diphtheria 
germs developing in the throat, and typhoid fever germs 
developing in the intestine, can readily escape from the 
body ; in the case of diphtheria, through the mouth and 
nose discharges; in the case of typhoid fever through 
the bowel, and sometimes the bladder, discharges. It 
is the escape by these channels of these germs from the 
body which makes these diseases " catching " or " infec- 
tious " or " communicable/' for if they could not escape 
from the body they could not reach other persons and 
therefore could not be "catching." But in human 
tuberculosis, most of the places where it develops, — 
bones, glands, joints, etc., — are not connected with any 
opening of the body by which the germs may leave the 
body. These forms of tuberculosis have no great high- 
way to the outside lying at their doors to carry the germs 
out to other persons. Practically only in human 
tuberculosis of the lungs is such a highway provided for 
the human tuberculosis germs, although sometimes in 
bladder, kidney, and intestinal tuberculosis. But in the 
latter forms, the germs do not, as a rule, pass out by the 
highways provided for them in such condition or such 
numbers as to be of serious importance in propagating 
the disease. In human lung tuberculosis, on the other 
hand, the windpipe, throat, and mouth form a highway, 
along which the germs may escape from the affected 



162 THE NEW PUBLIC HEALTH 

lung in such enormous numbers that twenty-four bil- 
lion per day have been detected in the discharges 
(sputum) from the lung of a single advanced case, al- 
though the average number from the average case is 
usually " only " four or five billion daily. 

Thus it comes about that human tuberculosis of the 
lungs is the only common form of human tuberculosis 
which is much to be feared as infectious. Practically 
all the chief forms of human tuberculosis are derived 
from the sputum of cases of human lung tuberculosis, 
carried chiefly by mouth-spray and on the hands, and if 
cases of human lung tuberculosis did not act to spread 
infection to other persons, all forms of human tubercu- 
losis would quickly disappear. 

Moreover, even human lung tuberculosis is not in- 
fectious in the early stages, i.e., when the germs are 
growing in the lung tissue, but have not yet reached the 
air-passages; because, until then, the germs cannot es- 
cape into the windpipe and so by the throat to the 
mouth. When in the later stages the germs reach the 
air-passages the way for the escape of the germs to the 
outside and so to other mouths is " open." Persons in 
this stage of tuberculosis are called " open " cases, and it 
is therefore only the u open " cases that are seriously to 
be feared as infectious. Because of this, tuberculosis is 
not spread much in the public schools. Many school 
children are tuberculous ; but open cases are not common. 
Sometimes the former should be taken out of school 
for their own good, but the latter alone are dangerous. 



COMMUNITY DEFENSE APPLIED 163 

THE ABOLITION OF CATTLE TUBERCULOSIS FEOM THE 

HUMAN 

Although the cattle tuberculosis germ differs from 
the human tuberculosis germ somewhat in size, shape, 
etc., the most important public health difference is this : 
the cattle tuberculosis germ seldom produces lung tuber- 
culosis in the human. It produces bone, gland, joint, 
etc., tuberculosis, but lung tuberculosis hardly ever. 
Consider how important this fact is. It means that 
cattle tuberculosis existing in a human can very seldom 
be conveyed from that human to another human. It 
other words, cattle tuberculosis may be transmitted 
from cattle to man, but practically is not further trans- 
mitted from man to man. To prevent cattle tubercu- 
losis in the human, we do not need to take into account 
existing cases of cattle tuberculosis in the human, but 
only existing cases of cattle tuberculosis in cattle. If 
we free our cattle of cattle tuberculosis, we shall free 
our humans of cattle tuberculosis also; and this is the 
only practical way that cattle tuberculosis in the human 
can be abolished unless and until the human race aban- 
dons the use of raw cow's milk. 

THE ABOLITION OF HTTMAST TUBEECULOSIS 

How can we abolish human tuberculosis? Exactly 
as we can, and some day shall, abolish any and all other 
infectious diseases, by killing off the germ that causes 



164 THE KEW PUBLIC HEALTH 

it ; exactly as we have almost abolished the race of buf- 
falo by killing off the existing buffalo. We know well 
enough that when the last buffalo is dead, no man, how- 
ever wise, no government, however powerful, could ever 
produce another buffalo. So, once the existing diph- 
theria or scarlet fever or tuberculosis germs are all dead, 
there is no way under heaven by which these particular 
germs could be produced again. Those which exist now 
are not " evolved from dirt " any more than are buffalo 
or roses. Those which are living to-day are simply the 
descendants of those which existed yesterday and so on, 
just as in the case of buffalo or roses, back to the dawn 
of history. Once any race of plant or animal is wiped 
out, it can never be redeveloped; and the tuberculosis 
germ, just as well as the germs of diphtheria or typhoid 
fever, can be abolished exactly as the megatherium or 
dinosaur has been abolished, i.e., by killing off the exist- 
ing individuals. 

" But consider the enormous numbers and the tiny 
size of germs and that they are present everywhere, — 
in air, water, food, milk, dust ; in and on everything we 
touch or taste or handle. It is quite impossible to kill 
them all." 

True, germs are everywhere but not disease germs. 
We know some fifteen hundred or more species of germs 
and hardly fifty of these produce disease, while only 
two, already mentioned, produce tuberculosis in the 
human. That these germs are very small and cannot 
be slaughtered individually like buffalo, is true, but it 



COMMUNITY DEFENSE APPLIED 165 

is also true that their very minuteness means that bil- 
lions can be slaughtered at a time, if they are only kept 
together. As to tuberculosis germs being everywhere, 
all over, outdoors and indoors — this is not true. No 
more important fact in public health has ever been for- 
mulated than this, due to that keen leader in public 
health, Chapin of Providence: The germs that pro- 
duce disease are not ubiquitous, not in dust everywhere, 
water everywhere, milk everywhere. They are chiefly, 
almost wholly, in the bodies of a relatively few people, 
or animals; and when they escape from those bodies, 
where alone they find the peculiar food, high tempera- 
ture, abundant moisture, and darkness which they need, 
they promptly die or become harmless. Even in water, 
milk, food, etc., into which they may be introduced 
from infected persons, their lives are short, and they 
must quickly reach a new living victim, or die. 

To abolish any one race of disease germs is far 
easier than to destroy some much larger things. Thus 
to abolish flies means not only killing all flies, indoors 
in all houses everywhere, in all stables everywhere, in 
and around all dwellings everywhere, but also through- 
out all fields and forests, mountains and valleys every- 
where, because flies are hardy outdoor beings as well as 
indoor beings. They can breed and flourish almost 
anywhere, where any kind of food, even in vanishing 
quantity, is to be had. Moreover, they can move of 
their own volition with promptness and despatch, have 
quick eyes and quicker wings to escape designing ene- 



166 THE NEW PUBLIC HEALTH 

mies, and in a thousand ways can take care of them- 
selves. 

Disease germs, in contrast with the fly, are very tiny 
and helpless particles of protoplasm, having no eyes to 
see an enemy, no nose to smell him, no means of run- 
ning away from him. They cannot flourish on almost 
any food, but need the living tissues of the human 
body ; they cannot grow at almost any temperature, but 
must have the heat of the human body. In brief, they 
are not merely indoor plants ; they are incubator plants 
and cannot grow, thrive, or reproduce themselves in 
nature, except in the incubators, which our bodies (or, 
in a few cases, animal bodies), provide for them. 
Hence if we were able to take a visual census of all the 
living tuberculosis or scarlet fever or diphtheria germs 
in the world we should see them, not in the dust every- 
where, the water everywhere, the food everywhere, etc., 
but in a very few places only, and those places would 
be, in almost all cases, the bodies of humans (or ani- 
mals). 

Indeed, we can foretell just about what the census of 
tuberculosis germs in any district of the temperate zone 
would show. It would show about one person in every 
five hundred of the population carrying a large number 
of active, living, growing germs in the lungs, — germs 
that were escaping to the outside and reaching other 
persons' mouths. It would also show a number of other 
persons in whom the germs were present in joints, bones, 
glands, etc., but not escaping to others; and it would 



COMMUNITY DEFENSE APPLIED 167 

show a number of persons affected in the lungs, and 
later likely to develop to the point where the germs 
could escape, but practically harmless to others so far. 
Beyond this, hunt high, hunt low, search garbage bar- 
rels, manure heaps, dead animals, dusty streets, sewage, 
water, foods, milk, etc., and human tuberculosis germs, 
alive, growing, capable of producing the disease, would 
seldom be found. True, in the immediate neighborhood 
of the " open " cases, the sputum they throw out, their 
mouth-spray, and their hands, would show the germs; 
and things they spit into, mouth-spray into, or touch, 
would show for a short time a few ; but these would be 
dying or already dead, holding out danger to other per- 
sons only during the short time which elapses between 
leaving their happy homes in the human lung and death 
outside from drying and starvation. This applies, not 
to tuberculosis germs alone, but practically to all the 
germs of the ordinary infectious diseases, anthrax and 
tetanus forming two chief exceptions, both compara- 
tively rare diseases in civil life. 

No person energetic enough to advocate the abolition 
of the fly should hesitate a moment to advocate the far 
simpler, smaller, easier, and far more important work 
of abolishing those germs that alone can make the fly a 
danger. 

In brief, the method, and, I believe, the only rapid, 
complete, effectual method of abolishing human tuber- 
culosis, is this : find the " open " cases and prevent the 
spread from them of the germs they alone throw out in 



168 THE NEW PUBLIC HEALTH 

numbers and condition to be feared. That means, find 
the one person in every five hundred whose infection 
threatens all the rest, and supervise him just enough to 
keep his discharges from entering other people's mouths. 

How is this one person in every five hundred to be 
found ? Not without hunting, not without ingenious, 
skillful, deliberate, sagacious, well-trained hunters, epi- 
demiologists as devoted and persistent in their work as 
the average insurance agent is in his, — men who devote 
themselves to the abolition of tuberculosis as whole- 
heartedly as any merchant does to making money. 

And how? Where shall we begin? Must we can- 
vass the whole population one by one? True, that 
would do it, but epidemiology has found a simpler, 
keener, more scientific, far more economic plan, illus- 
trated for typhoid fever in a previous chapter. Begin 
with the known cases and search the zones of infection 
surrounding each for mild, unrecognized, and concealed 
cases. (In tuberculosis the search for carriers is prob- 
ably unnecessary, certainly at the present time.) 

" But why not concentrate on the incipient lung case, 
the case that may be cured, and by preventing this case 
from going on to the c open ' infectious stage get rid of 
danger to others thus, instead of by attention to the 
open case ? w 

For several reasons the abolition of tuberculosis 
through care of incipient lung cases only cannot at pres- 
ent be accomplished. 

1st. Because incipient cases, in the truly incipient 



COMMUNITY DEFENSE APPLIED 169 

" non-open " stage, are discovered, perhaps are discov- 
erable, in a very small percentage only of their total 
number. 

2nd. Because a large proportion of the true incipi- 
ents so found would not go on in any case, whether 
found or not, to the open stage ; and the time and money 
and efforts spent in finding and supervising them would 
have been relatively wasted. 

3rd. Because a certain proportion of the incipients 
so found would go on, in any case, to the open stage, 
and thus become infectious cases, despite all efforts. 
In these alone would the efforts expended be of service 
in preventing new cases. The trouble is that, in the 
truly incipient stage, it could not be determined whether 
or not the case would so develop. 

4th. Because the time and attention devoted to in- 
cipients, in the effort to prevent them becoming open 
cases, would imply, as it has, too often, so far implied, 
neglect of the advanced " open " cases, from which the 
danger of infection is so immensely greater. 

5 th. Because if all the truly incipient cases were dis- 
covered they would form a mass of persons so great 
as to be beyond handling properly by any at present 
even dreamed of force of attendants, etc. If, as at 
present, only a very small proportion were found the 
actual situation would not be materially changed. 

" Would you then cease the care of incipient cases in 
sanatoria, and concentrate wholly on sanatoria or hos- 
pitals for the advanced case ? " 



170 THE NEW PUBLIC HEALTH 

No. First, because the tuberculosis sanatoria for 
incipients, intended though they are for incipient cases, 
really handle very many " open " cases, and to that ex- 
tent prevent new infections ; secondly, because the tuber- 
culosis sanatoria for incipients do, in a measure, fulfill 
their proper function of cure for incipients and even 
early " open " cases to some extent and hence save life. 
But as a means of abolishing tuberculosis, the ordinary 
tuberculosis sanatorium for incipient cases is quite hope- 
less. 

The thing to do first is, find the recognized " open " 
cases, whether they be in early, advanced, or late stages, 
and place them where they can spread the disease no 
further. 1 Then search the " zones of infection" sur- 
rounding them, i.e., their relatives and associates, for 
mild, unrecognized or concealed cases, and also for in- 
cipients, handling all " open n infectious cases thus 
found in the same manner. This system would begin 
at the right end by stopping further infection, and 
would incidentally find those early " open " and " non- 
open " incipient cases wherein sanatorium treatment 
would be of most avail. 

SUMMARY 

Human Tuberculosis is a typical infectious disease, 
and it must be handled on the same principles as any 

i The County Sanatoria of Minnesota, Wisconsin and many 
other States furnish exactly this place. They spell the abolition 
of tuberculosis if properly developed. 



COMMUNITY DEFENSE APPLIED 171 

other infectious disease; hence, by blocking the routes 
of infection, but chiefly by finding the sources and pre- 
venting spread thence. 

Of the five great routes of infection, — water, food, 
flies, milk, and contact, — human tuberculosis travels 
chiefly by contact, through sputum, mouth-spray, and 
hands, directly, or almost directly, from patient to 
prospective patient. Practically, it is spread exactly 
as scarlet fever or diphtheria is spread. 

Public flies and public food supplies are compara- 
tively insignificant conveyors of this disease. Public 
water supplies are almost negligible, and public milk 
supplies act chiefly in conveying cattle tuberculosis 
to man, although, if the milk be handled by tubercu- 
lous humans, it may convey human tuberculosis 
also. 

It is evident, then, that blocking the routes of human 
tuberculosis, since the chief one is contact, really in- 
volves the far more important measure of finding the 
sources, just as in scarlet fever, or diphtheria. If these 
sources are found and prevented from gaining access to 
the routes, the routes may be disregarded. The meas- 
ures for finding the human sources, practically the 
" open " cases of lung tuberculosis in the human, are 
epidemiological and have already been discussed in 
principle before (Chapter V). 

The transmission of cattle tuberculosis from cattle to 
human contrasts with the transmission of human tuber- 
culosis from human to human in that it occurs almost 



172 THE NEW PUBLIC HEALTH 

wholly by one definite route, raw milk; scarcely, if at 
all, through contact. 

Since this one route can be absolutely, easily, 
promptly, and inexpensively, blocked by the simple 
process of pasteurizing or otherwise killing the germs 
in the milk, there is no reason why we should await the 
equally absolute, but more difficult, much slower, and 
very much more expensive abolition of the sources, i.e., 
the elimination of tuberculous cattle from all herds, 
although the latter should be gradually pushed to com- 
pletion for economic reasons, whether the use of raw 
milk be abandoned or not. The measures necessary for 
finding the animal sources (infected milch cows) are 
the well-known tuberculin test of herds, with proper 
repetitions, and the elimination of the tuberculous ani- 
mals. 

Serious enough as cattle tuberculosis in the human 
is, its prevalence, nevertheless, is much less than that 
of human tuberculosis, its inf ectiveness from human to 
human is nearly negligible and the pasteurization of 
milk would eliminate it from the human. Hence, if 
our efforts were concentrated wholly on abolishing 
human tuberculosis from the human, more cases and 
more deaths would be prevented in one year's work, 
than efforts directed to abolishing bovine tuberculosis 
from cattle, however successful, could possibly achieve 
in many years. 



CHAPTEE XV 

THE CONTEOL OF DIPHTHERIA, SCAELET 
EEVEE AND MEASLES 

Without attempting to describe the technical de- 
tails, a sketch of the modern procedures, such as should 
be clear to all laymen dealing with the schools, is worth 
while as an illustration of the advances and advantages 
of the new practice. 

In past times, and of course even now, an outbreak 
of diphtheria in a school was considered the signal for 
" immediate action " — so far, so good. 

But that action often consisted chiefly in the closing 
of the school for disinfection, and reopening it again 
as soon as this ceremony of purification was performed. 
Should the scare be great enough the school, perhaps, 
all the schools of the community, were closed for weeks, 
to prevent spread of the disease amongst the children. 
The length of the period of closing was pure guess work. 
The time at which the schools were reopened seems usu- 
ally to have been decided by the condition of " scare " 
in the community. The outbreak sometimes ended in 
correlation with some one or more of these varieties of 
action. But very often, the outbreak spread while the 

173 



174 THE NEW PUBLIC HEALTH 

schools were closed, and if not, took a new lease of 
life when they were reopened. The children, ex- 
cluded from nearly all schools, were not effectively for- 
bidden to meet at play or work outside the school. 

The panic-origin of the method, its lack of clean-cut 
object, its " hit-or-missness," rendered it wholly unsat- 
isfactory as a scientific means of controlling the disease, 
to say nothing of the upset and loss of school time, 
the disturbance of the school finances, the degeneration 
of the school children thus forced to an uncertain vaca- 
tion, not provided for at home. 

The new method never interrupts the school at all. 
It brings to bear only so much pressure as is actually 
needed. The principle is simple — remove the infec- 
tion from the school. The practice is equally simple 
— discover by cultures of the children's throats x those 
who may be infected ; send them and their brothers and 
sisters home, and continue all the school operations as 
before with the remaining children. 

The infected children who are sent home must be 
followed to their homes and prevented from conveying 
their germs to uninfected companions out of school. 
They are in fact isolated until such time as (a) the 
germs they carry are shown by proper tests to be non- 
virulent or (b) the germs disappear, of themselves (as 
very often happens) or under treatment (lemon- juice 
or kaolin). 

i Not forgetting the throats of the teachers and of the janitor, 
also. Often cultures from noses also are advisable. 



DIPHTHEEIA AND SCARLET FEVER 175 

In institutions, a further step may be taken. 
Through the Schick test, the children who are immune 
to diphtheria, ranging perhaps an average of 50 to 60 
per cent, of all the children, may be kept together and 
all infected children may freely associate with them, 
without danger of disease. The non-immunes are like- 
wise kept in another group, and watched by culture and 
clinical observation for the development of further 
cases. This group may receive antitoxin also. 

The advantages of this simple procedure are too ob- 
vious for need of expression here. 

In scarlet fever, a very similar procedure was intro- 
duced and developed to a high degree of perfection by 
A. J. Chesley in Minnesota. 

The principle is exactly similar, but since the, as yet, 
hypothetical scarlet fever germ cannot of course be 
recognized as is the diphtheria germ, clinical observa- 
tion necessarily takes the place of cultures. 

As in diphtheria, the children are examined at the 
school; but by direct inspection of the face, tongue, 
throat, glands, chest, sometimes one foot : those showing 
signs of recent or developing scarlet fever are sent home, 
with their brothers and sisters, and the remaining chil- 
dren continue at school safely. 

Because scarlet fever may be incubating in children 
for several days before giving outward signs, the pro- 
cedure is further modified from that used in diphtheria 
to the extent that the inspection just described is re- 
peated every day for a week. All children still without 



176 THE KEW PUBLIC HEALTH 

signs of scarlet fever may then continue at school as 
safely as may those who, in a diphtheria epidemic, have 
had eliminated from amongst them the diphtheria in- 
fected throats. 

In scarlet fever, exactly as in diphtheria, the follow- 
ing up to their homes and isolation there of the in- 
fected children is an essential to prevent spread from 
them amongst school children after school hours, or 
amongst non-school children they may otherwise en- 
counter. 

Quite similar methods may be and have been suc- 
cessfully applied to measles. In this disease, the infec- 
tious period begins three or four days before the rash, 
with the beginning of the earliest symptoms, which usu- 
ally are first observed as, and often taken to be, those of 
a heavy cold, with reddened eyes and hoarseness. All 
schools should stand ready to eliminate from amongst 
their pupils all sick children — for the sake of the child 
itself, but even more for the sake of its associates. 
Such children should not only be sent home, but should 
not be returned to school again without a medical in- 
spection, preferably by a school physician. 

SUMMARY 

Some day infection will be so well controlled outside 
the schools that infected children will not enter schools ; 
and then, school outbreaks will be unknown. But in 
the transition period from the diluted barbarism of to- 
day to the conditions just outlined, diphtheria, scarlet 



DIPHTHERIA AND SCAELET FEVER 177 

fever and measles can be detected and eliminated from 
schools, and best by keeping the schools open, not by 
closing them, provided the methods outlined above are 
followed. 

ISTot only do these methods keep the schools free of 
infection and hence make them " the safest place in 
town," but also the follow-up system, also outlined, 
provides for the elimination of out-of -school infection 
from the community. 

Of course, both within and outside the schools, the 
epidemiologist, thoroughly posted on the natural his- 
tory of the diseases he deals with and keen to trace its 
sources and its routes, is a sine qua non. 



CHAPTER XVI 
VENEREAL DISEASES 

We know how to prevent any infectious disease the 
moment we know where its sources are, if we can con- 
trol them. 

In tuberculosis we are getting control slowly of the 
two main sources and routes, tuberculous cattle and the 
raw milk from them for bovine tuberculosis, the human 
consumptive and his mouth discharges for human tuber- 
culosis. 

In typhoid fever, scarlet fever, diphtheria, etc., ex- 
actly the same things are true and exactly the same sort 
of principles are to be applied, and have been applied 
most brilliantly and successfully. 

In the venereal diseases, however, although the same 
principles of course remain as true as ever, their appli- 
cation to the sociological conditions of the day have yet 
to be worked out upon a practical footing. 

The people, as a whole, have overlooked the fact that 

more than half of the cases are innocently contracted, 

and attach a stigma to all that is deserved by few. 

Hence one great difficulty in the discovery of cases, and 

the difficulty in dealing with them after their discovery. 

178 



VENEEEAL DISEASES 179 

Moral suasion has been tried for thousands of years, 
and venereal diseases have increased instead of dimin- 
ishing. 

The elimination of these diseases from the race is the 
practical duty of the professional public health man and 
he every year considers it more seriously. 

Preliminary steps have been taken to determine the 
extent of the problem, with appalling results, but these 
should rather urge to more immediate and strenuous ac- 
tion than result in inertia and despair. 

It has been pointed out elsewhere that education of 
the average person to avoid other diseases is, while 
worth while, of little final value, because infection can- 
not be recognized by laymen, nor can the channels by 
which it travels be so continuously blocked in ordinary 
life as to avoid unrecognized infection ; hence that it is 
the duty of the community to eliminate infection from 
itself entirely and free its members of all need for per- 
sonal defence. This is everywhere recognized as sound 
governmental policy in relation to other dangers, fire, 
thieves, invaders — why not in relation to these more 
constant, more inevitable and more insidious foes ? 

The sources of infection are the venereally infected 
persons who now exist. Unfortunately these are not 
confined to any group or class or profession, but are 
scattered everywhere. 

The routes of transmission are intimate contact, but 
not necessarily sexual, or when sexual, not necessarily 
guilty ; yet of a nature making the tracing of transmis- 



180 THE NEW PUBLIC HEALTH 

sion rather a delicate task. The control of the infected 
heretofore has not been recognized as anything like so 
important as the control of scarlet fever or diphtheria 
infection, despite the far greater damage that they do. 

While prophylactic disinfection may be and has been 
practised with great success in naval and military cir- 
cles, the apparent endorsement that arrangements to 
this end give to illicit relations makes it difficult to en- 
join or even urge them in civil life. 

Hence the venereal problem, while gradually taking 
shape, is as yet hardly concrete enough to permit formu- 
lation of a definite program. 

All that can really be held as absolutely demonstrated 
is this : however the solution may be reached, it neces- 
sarily must involve one, two or more of the simple 
principles established for the control of other infections : 
immunization, avoidance of the sources, blocking of the 
routes, elimination of the sources; the latter being the 
highest ideal. The first is as yet hypothetical; the 
second has totally failed to eliminate these diseases 
from the race, although a perfect method when 
practicable and practised. The third is the only method 
successful to date on any scale large enough to offer 
evidence of its efficiency. The fourth is as yet a dream. 

Education of children in sexual hygiene cannot but 
be of benefit in some cases and while no final solution 
of the problem, paves the way to it by doing away with 
the false modesty that envelopes these great scourges 



VENEREAL DISEASES 181 

of the race in a sanctified mystery of misery that con- 
duces greatly to their successful propagation. 

Wherever " hush " is heard, wherever mystery and 
mysticism reign, there we find superstitious practices 
and suffering beyond belief. 

" The dark places of the earth are full of cruelty " — 
and doubtless after all is said and done, publicity will 
prove if not the solution, the first step to the solution, 
of this our greatest present day public health question. 



CHAPTEE XVII 

THE CONCLUSION OF THE WHOLE 
MATTER 

THE DOING OF IT 

If previous chapters have succeeded in the very 
earnest attempt they made to show what the new public 
health principles are and how they have become estab- 
lished, the one momentous matter in public health still 
left unsolved is this — why, why, why are not these 
principles observed ? If we know how to do it, why is 
it not done ? 

Chiefly, because the general public does not know. 
They still believe religiously the theories that were be- 
ginning to be discarded in scientific circles twenty years 
ago. To any one who has discussed these subjects be- 
fore lay audiences it becomes most evident that people 
the most refined and educated still believe, concerning 
public health, almost the same things that the most ig- 
norant hold. 

How many people believe that gold wedding rings 
rubbed on the eye will cure styes ? That green apples 
cause colic? That ear-rings improve sight? That 
a copper wire round the waist prevents rheumatism? 

182 



CONCLUSION OF WHOLE MATTER 183 

That horse-hairs soaked in water become snakes ? That 
only nasty medicines cure? That whiskey is good for 
pretty nearly any ailment ? That the moon affects luna- 
tics? That tuberculosis is hereditary? That measles 
is inevitable ? That typhoid comes from dead weeds in 
drinking water? That red flannel (must be red!) is 
good for sore throats? That sewer gas is poison? 
That smallpox can be telephoned from one person to 
another? That mosquitoes come from decomposing 
leaves? That malaria is due to night-air? That ro- 
bust people do not have smallpox? That scarlet fever 
scales are infectious? That raw beef -steak is good for 
a black eye ? That drinking cow's blood cures consump- 
tion ? That the smell from a horse stable cures consump- 
tion? That if medicine is good for sick people, it 
must be still better for well ones ? That eating turnips 
makes one brave ? That onions cure or prevent small- 
pox ? That dead bodies necessarily breed a pestilence ? 
That rusty nails produce tetanus (lock-jaw) ? That 
goats in a stable save the horses from glanders ? That 
in epidemics schools should be closed? That Cuban 
Itch is not smallpox? That washing the exterior of 
the body removes disease from the interior of the body ? 
That children ought to have " children's diseases " ? 
That the younger they have them the better ? That all 
colds are due to cold ? That fever is due to heat ? That 
brain-fever comes from excitement or strain? That 
people " gradually run down, and it turns into " typhoid 
or tuberculosis? That backache indicates kidney 



184 THE NEW PUBLIC HEALTH 

trouble? That vaccination is worse than smallpox? 
That you " mustn't give in to " disease, but fight it ofi 
by force of sticking at your work ? That cold weather is 
healthy because it kills germs ? That oxygen kills dis- 
ease germs? That small flies grow into big ones? 
That cancers have roots like a tree; roots which can 
be drawn out with the cancer, if care is exercised? 
That grapeseeds produce appendicitis? That cherry- 
stones swallowed may grow a cherry tree in your stom- 
ach ? That pickles sour the milk of a nursing mother ? 
That a meat diet tends to produce a quarrelsome dis- 
position ? That there is no danger of infection from a 
sick child unless a doctor has pronounced exactly what 
the particular disease is ? That mild attacks of infec- 
tious diseases are less infectious than severe ones ?' 

So long as this jumble of pure myth, current tradi- 
tion, childhood misunderstandings carried over uncon- 
sciously into the serious repertoire of adult conceptions, 
control and form the basis of procedure for the public 
health thought and action of the race, so long will pub- 
lic health be what it largely is to-day, a farce and laugh- 
ing stock. 

Until these absurdities are definitely combated and 
eliminated, the teaching of the truth is retarded, for the 
public tend, not to replace the superstition by the fact, 
but to adjust one to the other, making a more hideous 
jumble than ever. Curiously also, it is the fact that is 
modified in such adjustment, not the superstition. We, 
as a race, pride ourselves on our cold-blooded, calculat- 



CONCLUSION OF WHOLE MATTER 185 

ing analysis of things, our elimination of old-world 
formulas, of old-world rules. Yet in public health, 
nothing is too ridiculous or far-fetched to find ready 
believers — eager strivers after mystery, people who 
prefer complicated non-sequitors to simple facts. 

Four of the most common fallacies the writer's ex- 
perience of public discussion has elicited are illustrated 
here, and the reader may easily test his own state of 
knowledge by asking himself what answers he would 
give to the questions here presented : 

THE CHIEF OBJECTIONS 

1. If the disease germs are not evolved afresh from 
dirt or decomposition, but are descendants of their fore- 
fathers, where did the first disease germ come from ? 

We do not know. Where did the first wheat come 
from ? Or the first horse ? We know that we can get 
no wheat now, except from wheat, nor horses except 
from horses. These germs are plants or animals, ex- 
actly as wheat or horses are. That they are tiny no 
more changes this law of descent than does the enormous 
size of a whale or of a redwood tree make them excep- 
tions. " All life from life " holds true in nature 
through the whole scale, from germ to human beings. 
Besides, under the microscope, we see the germs " de- 
scending " from their forefathers. 

2. If dirt does not breed disease, then why are dirty 
people so subject to disease ? 

Dirty people are no more subject to disease than 



186 THE NEW PUBLIC HEALTH 

clean. Infection, if it reaches either, may yield dis- 
ease, in either ; if it reaches neither, neither will suffer. 
If an infectious disease enters a household, the dirtiest 
people will not spread it, despite their dirty habits, if 
they avoid the one specific " dirt " (the discharges of 
the patient) which alone is harmful ; the cleanest people 
will not fail to catch it if, in their general cleanliness, 
they neglect that same specific " dirt." True, dirt, 
carelessness and disorder offer some indication whether 
or not the people who show these characteristics would 
have the sense, or take the trouble, to avoid the one dan- 
gerous " dirt/' should it appear. On the other hand, 
cleanliness, thrift, and system indicate characters likely 
to handle infectious " dirt " with the same care they 
show in other matters. But the dirtiest people who 
make the proper efforts to avoid infection can and do 
many times escape, remaining as dirty as they please in 
other ways. The cleanest people who neglect or do not 
know the methods can and do suffer. 

3. If you tell people " dirt n does not breed disease, 
you are praising dirt — upsetting all the careful up- 
lift all the best people have attempted for many, many 
years. 

Suppose a ivater-^vp® is leaking in your house, flood- 
ing the floors and damaging everything. Suppose that 
when the plumber is hurried to the rescue, he tests the 
^as-pipes, finds a leak, stops it, and tells you all is well. 
What would you say? True, the gas leaked; it was 
right to stop it 5 but the water goes flowing on ! Sup- 



CONCLUSION OF WHOLE MATTER 187 

pose to your objections he replies : " But think how 
bad the effect would be on our campaign against gas- 
leaks, if we failed to urge that gas-leaks must be 
stopped, whether that stops the water-leaks or not. If 
I admit that gas-leaks have no connection with water- 
leaks, you would let the gas flow on. I must make you 
believe the water-leak depends on the gas-leak, else you 
won't fix the gas-leak." Stopping gas-leaks cannot help 
water-leaks nor vice versa. Reducing disease will not 
make people " clean/' nor will making people " clean " 
reduce disease ; only the one " cleanliness " of avoiding 
infected discharges will gain this end. 

4. Why do you talk so much about disease? Teach 
healthy living, keep the body strong, well clothed, well 
fed, and you need not fear disease, especially infectious 
disease, at all. 

This is a fallacy so widespread that even physicians 
teach it, in good faith, without considering that they 
themselves would never let their own children, be they 
never so healthy, run with a measles case, or mumps, or 
scarlet fever, unless their children had had the disease 
before. If the teaching is not good enough for prac- 
tical application to physician's children, it is not good 
enough for public health. 

You see, every one knows that children who have had 
measles very seldom take it a second time, and this with- 
out regard to whether they are robust or sickly, healthy 
or weak. Every one knows, too, that children, healthy 
or sickly, who have not yet had measles, almost invari- 



188 THE NEW PUBLIC HEALTH 

ably catch it if they are exposed. Practically, the same 
is true of scarlet fever, mumps, whooping cough, small- 
pox, chickenpox, etc. It is not so true of tuberculosis, 
diphtheria, or typhoid, since those who have had tuber- 
culosis, diphtheria, or typhoid may take it again; al- 
though again without regard to whether they are healthy 
or sickly. 

In measles and the other diseases like it, persons ex- 
posed who do not contract the disease, escape, not from 
good health, but just because they have within their 
bodies a certain antidote to the particular poison of that 
particular disease. Any one can prove this to himself, 
if he will think a moment. If general good health 
really did protect against these diseases, a child who 
could not catch measles, because protected by his gen- 
eral good health, could not catch scarlet fever, either, 
for the same general health would save him from them 
both. But every one knows that the child who cannot 
catch measles (because he has had it) must nevertheless 
be guarded from scarlet fever, unless he has had that 
too. In brief, an attack of these diseases gives, in 
most persons, an immunity; that is, an antidote is 
formed, which then protects them from having it again. 
But there is a different antidote for each disease. Hav- 
ing had measles once is excellent protection against 
measles, but it is no protection at all against scarlet 
fever or mumps or any other illness. 

In diphtheria an antidote is formed, but often disap- 
pears again, and therefore this disease may be suffered 



CONCLUSION OF WHOLE MATTEE 189 

more than once. In typhoid also an antidote is formed 
lasting a year or two. We know something, and are 
learning more, of this antidote against typhoid. We do 
not know yet much about that which perhaps protects 
against tuberculosis. 

Now, no one dreams that the antidote for measles can 
be developed by diet, exercise, or clothing ; by fresh air, 
drugs, or anything in fact, except by suffering an at- 
tack from the measles germ. Nor can any one seriously 
believe that the antidotes for typhoid or chickenpox, 
etc. (except that for smallpox vaccination takes the 
place of an attack of smallpox), can be developed except 
by equivalent means. If " good health " will not pro- 
tect against any of these diseases, taken one by one, how 
can " good health " protect against all of them taken to- 
gether ? 

So we might deal with fallacy after fallacy, all based, 
however, on two. 

POPULAR FALLACIES 

The first of these is that infectious diseases come 
from " general bad surroundings." The truth is that 
they come solely from certain germs growing in the 
body, and practically the only sort of " bad surround- 
ings " which causes infection is association with one of 
these infected bodies or with its discharges. 

The second great basic fallacy is this, that " general 
good health " protects against infection. The truth is, 
that the only true protections against germs we know 



190 THE NEW PUBLIC HEALTH 

are, first and best, to keep them out of the body ; and, 
second, to have within the body the special antidote for 
each particular germ. We vaccinate against smallpox, 
but that does not save us from typhoid fever. We vac- 
cinate against typhoid fever, but that does not save us 
from smallpox. If we could vaccinate against every 
disease (as perhaps some day we shall be able to do) 
we would be safe, despite the germs, at least while the 
protection lasted, and after that we could vaccinate 
again. 

But how much better to abolish the germs, which 
means guarding all persons in whom they are ; and then 
we would never need any sort of vaccination ! 

Surely, the thing to do for one's own sake, and still 
more for the sake of our associates, is to find the in- 
fected persons, or animals, that alone can cause disease 
in the true sense, and keep them so protected while the 
danger lasts that they will do no harm. Then, when 
their stock of germs is dead and done with, remove all 
the restrictions. 

NEW FASHIONED QUAKANTINE 

Tou will say that that is only old-fashioned quaran- 
tine. It is, in principle, but modern practice changes 
it so completely that, practically speaking, new-fash- 
ioned quarantine differs from old as much as motor cars 
differ from camels, although both are means of locomo- 
tion. In the first place, old-fashioned quarantine did 
not pick out all dangerous persons, but took the sick who 



CONCLUSION OF WHOLE MATTER 191 

form but part of the infected, and also took the well who 
were found with the sick, including thus some who were 
not infected, and kept all these practically in prison, in 
their homes, or ships, or wherever else they were stay- 
ing. Thus, not alone were many infected persons over- 
looked and many uninfected persons wrongly held, but 
also the disease spread oftentimes from those infected 
who were in the net to the uninfected who were kept in 
with them, so that old-fashioned quarantine, while it 
protected the community but partially, meant often 
poverty, disease, and death to those caught in its toils. 
No wonder the very name of quarantine makes many 
people shudder. 

New-fashioned quarantine is not a blanket method, 
blunderingly catching in its blindfold grip both sick and 
well, the harmless and the harmful, indiscriminately. 
New-fashioned quarantine requires definite detailed 
knowledge applied with care and patience, not mere 
force. 

Now, every one wishes infectious persons handled so 
that infection ceases. The infectious persons them- 
selves do not wish to spread their own infection. The 
thing that chafes and riles the average person is not re- 
striction but unjust restriction; either restriction of 
non-dangerous persons, or restriction of some of the 
dangerous only, while others just as dangerous go 
free. 

No mother minds the exclusion of her infectious child 
from public school, if her neighbor's infectious child is 



192 THE NEW PUBLIC HEALTH 

excluded also. Every physician would report his cases 
if every other physician did so too. 

Here then is the solution, based on human nature, on 
common sense, and on the most scientific knowledge. 
Find, through the methods of epidemiology, of the 
laboratory, and of the vital statistician, skilfully com- 
bined by experts, these dangerous persons, whether sick 
or well — these only dangerous persons, those who 
carry on them or in them, germs of infectious diseases. 
Set all others free, but keep these persons, not in old- 
fashioned quarantine, but under such control that their 
discharges will not pass to others ; and do not measure 
the length of that control by fixed time limits, blind and 
unjust as quarantine itself, but measure it wholly by the 
length of time the germs remain in or on the body. 
The moment that the germs have left those persons they 
are no longer harmful and they should be freed. 

To do this properly means intimate attention and 
supervision of infectious persons by men who know 
their business and do nothing else. If one such man 
to every 20,000 persons began, to-morrow, everywhere, 
his work, infectious diseases in ten years would have 
vanished and would have become mere history. 

SUMMAKY 

This, then, is the conclusion. The old ideas have 
passed; the new are no longer theories but facts; the 
methods they require are not untried; they have been 
practiced for years in many places. The details are 



CONCLUSION OF WHOLE MATTER 193 

worked out, the field is ready, the scope and cost are 
known. All that remains is to apply the methods al- 
ready developed to all infections, thus wiping them 
all out, once and for all. The way is clear, what re- 
mains is to follow it ; the method is known, what remains 
is to carry it out ; the thing we, as a race, for centuries 
have prayed for, can be done ; all that remains is to do 
it. 

Each generation of Americans pays now for infec- 
tious disease ten billion dollars at the least, and has the 
diseases, too ! Why not pay one-tenth this sum and rid 
ourselves of all of them forever ? 



APPENDIX I 



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APPENDIX II 
SYLLABUS OF PUBLIC HEALTH TEACHING 

As an example of the sort of material which should 
be presented to school children, the following syllabus 
already in use in Minnesota is appended. This was 
prepared by the writer in co-operation with Mr. C. G. 
Schulz, State Superintendent of Education. It was 
intended to supply to the public school teachers of the 
State a condensed but accurate outline which they 
should then put into their own words for the informa- 
tion of their pupils. Syllabus No. 1 might well be 
taught in all grades; syllabus No. 2, in whole or in 
part, in all grades; syllabus No. 3, in the sixth and 
higher grades ; while syllabus No. 4 is applicable rather 
to the eighth and higher grades, thus including the high 
and normal schools. 

Elementary and simple as the information given 
may appear to those who are conversant with all 
phases of Public Health, the writer's experience is that 
the most enlightened and well-educated of those of the 
laity who received their education in times past, when 
nothing of this nature was offered, find in these leaf- 
lets a very great deal of information which is to them 
new, intensely interesting, and often quite revolution- 

197 



198 APPENDIX 

ary. These leaflets have been prepared with the utmost 
care and submitted to a number of the highest author- 
ities in each subject treated of, in order to assure the 
strict accuracy and up-to-dateness of the statements 
made. 

Prepared by H. W. HILL, M.B., M.D., D.P.H. 
No. 1. GEEMS AND DISEASE 

1. Not less than 1500 kinds of germs exist — but only 
about 50 to 75 produce disease. Remember these two classes : 

(a) disease germs and (b) all other kinds. 

2. Germs of all kinds are simply tiny plants (or animals) ; 
some spherical, some more or less sausage shaped; so small 
that from 100,000,000 to 200,000,000 might lie side by side 
on a thumbnail, yet could not be seen. 

3. Germs of any kind never " evolve " from dirt. They, 
like other plants (or animals), come only from predecessors. 
They increase in number by single germs separating into 
two ; then each of these grows and likewise separates ; this is 
repeated about every twenty minutes, when conditions are 
good for the germs, giving about 1,000,000,000 descendants in 
ten hours. 

4. Conditions good for the germs mean: (a) much water, 

(b) the right food, (c) the right temperature, (d) darkness, 
(e) the right atmosphere. These differ for different kinds 
of germs; most disease germs find the living body the best 
place for them : when they leave it, sunlight and drying soon 
kill or disable them. 

5. Many different kinds of germs that do not produce dis- 
ease flourish on or in our skins, noses, mouths and intestines 
all the time. 

6. We all pass our germs on to other people whom we meet, 



APPENDIX 199 

and they pass theirs on to us. But this does no harm, unless 
disease germs are present too. Disease germs are found 
chiefly in persons who have or have had some infectious 
disease. 

7. Neither disease germs nor other kinds can jump or fly 
from one person to another; they are carried, chiefly in the 
discharges from the nose, mouth, bladder and bowel. 

8. These discharges are exchanged chiefly by mouthspray, 
sputum, and hands; also by things touched by mouthspray, 
sputum or hands. 

9. Mouthspray means the small, sometimes invisible, drops 
of liquid from the mouth that we throw out when we sneeze 
or cough or talk or sing or shout; in quiet breathing they 
are not thrown out. 

10. Sputum is spit — the liquid from the mouth, gener- 
ally mixed with liquid from the nose or lungs. When it is 
thrown out where it can be stepped on it may be carried to 
other people, chiefly on feet of animals or shoes of humans. 

11. Hands, most of all, carry all kinds of germs from one 
person to another because hands carry mouthspray, sputum, 
nose, bladder and bowel discharges to other people's hands, 
and to things that other people touch. 

12. Although most healthy people's germs are not disease 
germs and are therefore harmless to other people, it is hard 
to tell when even healthy people may get disease germs from 
some one else — therefore 

13. Try to keep your hands out of your mouth and nose, 
and away from other discharges, unless they are washed well 
before (for your sake) and then washed well afterwards (for 
others' sake). 

14. Try not to handle any food, cups, spoons, or other 
things which other people may put into their mouths, unless 
your hands are first washed clean from your own nose, mouth, 
bowel and bladder discharges. 



200 APPENDIX 

15. Try not to leave any fresh moist discharges from your 
body where other people or animals will touch them, or step 
on them; or where flies will get at them and carry them to 
other people's food. 

16. Water and milk, as well as food and flies, carry dis- 
charges to other people. Therefore don't let your discharges 
get into or on any of them. 

17. Try to get other people to be as careful as you are. 

18. Try not to let other people pass on their germs to you, 

ESPECIALLY IF THEY HAVE ANY KIND OF DISEASE GERMS (tuberCU- 

losis, typhoid, scarlet fever, measles, etc.). 

No. 2. FOOD AND WATEK 

1. Food and water, next to ourselves, are the most im- 
portant physical things, for they are what we are made of; 
we are about 70 per cent, water, the rest food. 

2. When first born, we weigh about 7 to 8 lbs., as adults 
120 to 200 lbs. The difference comes from part of the food 
and water we have taken in. 

3. A large part of the food we eat does not become part of 
us, but is burned up as fuel to keep our bodies going. Chil- 
dren usually gain weight fast; because they eat more than 
they burn up. Adults usually do not gain weight much; 
because they burn up about as much as they eat. 

4. Our food comes, directly or indirectly, from the soil — 
the crust of the earth. Therefore we are made of the crust 
of the earth. So are all plants and animals. 

5. The crust of the earth is made up of about 80 elements 
— about one-fourth of these go to form our bodies. These 
include carbon (found in diamonds and coal), oxygen, hy- 
drogen (found in air and water), nitrogen (found in air), 
phosphorus, sulphur, sodium, potassium, calcium* magnesium, 
iron, chlorine, iodine, fluorine, etc. (found in various salts 
in food and water). 



APPENDIX 201 

6. We cannot feed ourselves on these elements; they must 
be combined from the soil, air, and water by bacteria and 
plants into forms we can use; often we get the combinations 
we need by eating animals, which themselves live on plants. 

7. The chief combinations we can use are known as fats, 
carbohydrates, proteins, vitamins, salts, water. 

8. Fats (including oils) are found in fat of animals (lard, 
suet, etc.) ; and oil of plants (olive oil, peanut butter, etc.). 
They consist of carbon, oxygen and hydrogen. 

9. Carbohydrates are combinations of carbon, oxygen and 
hydrogen also, but differ from fats in the way they are put 
together. They include starches and sugars. 

10. Proteins form the main substance of white of egg, lean 
meat, lean fish; and are found also in plants. Proteins are 
combinations of carbon, oxygen, hydrogen, and nitrogen, 
with phosphorus, sulphur, and other elements present in 
various amounts. 

11. Vitamins are peculiar things, essential to nutrition; 
they are present in raw plants, fresh milk, etc. 

12. Salts are combinations of calcium, magnesium, etc., 
with oxygen, hydrogen, etc.: they are useful in many ways 
in the body; calcium especially in forming bone. 

13. Water is the great solvent and carrier of material from 
place to place in the body: blood is nearly all water, and 
carries food and oxygen to the muscles, brain, etc., and 
waste matter from them to the kidneys and lungs. 

14. Since the really living parts of us are largely protein, 
only protein can be used to repair waste or add to our bodies. 
We cannot long survive on a diet without protein in it. 

15. But part of the protein we eat and all of the fat, oil, 
starch and sugar is useful only as fuel. 

16. All of this fuel is burned in the body, in the muscles, 
brain, etc. Our lungs make the draft for the fire, and let 
out the " smoke," carbonic acid. (See " Air," par. 4 and 5.) 



202 APPENDIX 

17. Fats and carbohydrates, if not burned up at once, are 
stored as fat; some carbohydrate is stored as animal starch 
(glycogen) in liver and muscle. Sugar and starch in excess 
make people stout. 

18. Fat in the body is stored fuel, ready for use on occa- 
sion. Very thin people have no reserve fuel, very fat people 
have too much. 

19. Children under one year should have water and human 
milk — nothing else, if possible. 

20. Children over one year should be carefully taught to 
use all good " adult " foods ; fats, carbohydrates, proteins, 
vitamins, salts, water. 

21. All growing children need protein, to add to their 
bodies as well as to repair waste. Sugar, starch, and fats, 
are good fuels for children. 

22. Healthy adults need protein for repair of waste only. 

23. Boys from 9-13 need as much protein as a man. Boys 
from 14^19 need more. 

24. Girls of 11 need as much as women of 30. Children 
need proteins in summer, although they are said to be " heat- 
ing." Cool the children by proper radiation, not by protein 
starvation. (See " Air," par. 3.) 

25. To be sure of vitamins, use some fresh raw food (fruit, 
etc.) every day. 

No. 3. AIR 

1. The important points about ordinary air relate to its 
oxygen, nitrogen, carbonic acid, water vapor, temperature, 
circulation. We use air for (a) cooling, (b) breathing. 
Normal air consists of about one-fifth oxygen, four-fifths 
nitrogen and four parts in 10,000 carbonic acid. The water 
vapor varies very much. 

2. We are like internal combustion engines (see " Food," 



APPENDIX 203 

par. 16) in that we need cooling; like an automobile engine, 
we are cooled by air and water. 

3. The skin is our great radiator; the air itself cools our 
skins directly; and also by evaporating the water (sweat) 
that we constantly pour out on our skins. 

4. We are like engines also in that we use air to help burn 
our fuel (see " Food," par. 16). We draw the oxygen through 
our lungs to the blood, which carries the oxygen to all parts 
of the body, and brings back the carbonic acid. 

5. The " smoke " we make is invisible ; it is the carbonic 
acid we throw out from our lungs. 

6. The old idea of "good ventilation" largely neglected 
water vapor, temperature and circulation, and concerned 
itself chiefly with oxygen, nitrogen and carbonic acid: it 
recognized breathing but overlooked cooling. 

7. The new discoveries (Fliigge, Leonard Hill, etc., during 
the last 8 or 10 years) show that air seldom can be too bad 
to breathe: it is very often too bad for successful cool- 
ing. 

8. This means that ordinary "bad air" is not bad on 
account of its effects on the lungs, but on account of its 
effects on the skin. 

9. Thus, experimentally, men in "foul" air, suffering 
headache, drowsiness, etc. (the result of bad ventilation in 
an airtight room), were allowed to breathe good air through 
tubes leading to the outside of the room. They were not 
helped by it. Men, outside the room, in good air, were forced 
to breathe the foul air through tubes. They were not hurt 
by it. 

10. True it is theoretically possible, in a really airtight 
room, to use up the oxygen in breathing and fill the room 
with carbonic acid thrown out from the lungs. 

11. But our houses and rooms are not airtight: oxygen 



204 APPENDIX 

will pass in through the walls themselves, if no windows or 
doors are open : carbonic acid will pass out through the walls. 
This is especially true in winter, when the temperatures 
inside and out differ much. 

12. Therefore "bad air," which gives headaches, makes 
people drowsy, etc., is not bad from lack of oxygen, or from 
too much carbonic acid. 

13. " Bad air " is bad from too much humidity, too great 
heat, or both. The victims of the Black Hole of Calcutta 
died of " heat stroke," not from lack of oxygen or too much 
carbonic acid. Suppose you run an automobile without any 
cooling device! Exactly similar is the effect of too much 
heat or too much humidity, or both, on the human en- 
gine. 

14. In winter, most houses are too dry. This means ex- 
cessive evaporation from the body, chilling it, and the house 
must be heated excessively (to 70 or 75 degrees Fahrenheit) 
to make up. Evaporating water in the house in winter to 
raise the humidity from 30 per cent, (now usual) to 60 per 
cent, (the proper figure) reduces the temperature necessary 
for comfort to 60 degrees Fahrenheit; and saves coal. 

15. In summer, humidity, as well as heat, is too high as a 
rule. These are hard to control, but the " heat and humidity 
blanket" which we ourselves make by warming up the air 
immediately around our own bodies with our own heat and 
saturating it with our own evaporated sweat can be dissi- 
pated by a breeze, an electric fan, or moving about gently. 
In winter outdoors, we keep our "heat and humidity blan- 
ket" close to our skins by our clothing. 

16. Children, especially babies, suffer from heat and hu- 
midity and for health in summer require light clothing or 
none, and circulation of air. In winter they need warm, 
loose clothing. 



APPENDIX 205 

No. 4. MEDICAL SUPEEVISION OF SCHOOLS 

1. Medical supervision of schools means a physician watch- 
ing over the children, to find where they are weak in their 
bodies; and to prevent outbreaks of infectious diseases; just 
as the teacher watches over them to find where the children 
are weak in their studies ; and to prevent disorder. 

2. It is true that every teacher should watch the children 
for evident bodily defects, poor sight, deafness, sickness; and 
should report these to the principal, or school board for 
action. But teachers are not trained medical men and can- 
not be expected to do such work perfectly. 

3. The best system of medical school supervision consists 
in having a full-time physician, expert in this work, with two 
trained nurse assistants.* Such supervision has two main 
purposes: I. to (a) discover, and (b) prevent the spread of, 
infectious diseases; II. to (a) discover, and (b) provide for 
the correction of, physical defects. But it also helps in — 

(a) the discovery of mental peculiarities of the children, 

(b) the discovery of unsanitary conditions in the school, 

(c) the provision of the best seating, lighting, heating, 

and other similar matters, 

(d) the promotion of cleanliness, order and decency. 
This method 1. prevents epidemics, 

2. promotes general health, 

3. makes a safe, sanitary school. 

4. Where a full-time physician specialist cannot be se- 
cured, part time of private practising physicians helps; but 
full-time nurses should be employed as well. 

5. Where only one inspection can be secured during a 
school year, it should be conducted at the opening of the fall 
term; if two, at the opening of the fall term, and after the 
Christmas holidays. These single inspections — 

* This is the proportion for a population of 20,000. 



206 APPENDIX 

(a) prevent carrying over vacation epidemics into the 

schools, 

(b) help to detect the more obvious defects and disabili- 

ties of the children. 
They do not aid in the discovery of epidemics during the 
school term; nor in the detection of the defects or disabilities 
developing after attendance at school has begun. 

6. The employment of school nurses alone, without any 
physician as supervisor, accomplishes a good deal in the di- 
rection of cleanliness, the following up of obvious cases of 
disease, defect, or disability, and helps in truancy. But it 
neither prevents epidemics nor promotes health, mental effi- 
ciency, or general sanitation in a thorough-going way. 

7. Emergency medical supervision is conducted in epi- 
demics, to detect infected children and protect the others. 
This is the best method for getting rid of the disease and it 
does this without closing the schools : it can be done in any 
school, at any time, without cost, on application to the State 
Board of Health. 

8. Medical school supervision should be supplemented by 
pre-school supervision; that is, supervision of prospective 
scholars, children now under school age who will later go to 
school; and by instruction to mothers before and after the 
birth of their children, so that the children will not have so 
many defects and disabilities to correct later. 

No. 1. Germs and Disease, should be taught in ALL grades. 

No. 2. Food and Water, may be taught in whole or in 
part to all grades. 

No. S. Air, should be taught in the sixth and higher grades. 

No. Jf. Medical School Supervision, should be taught in 
the eighth and higher grades. 

PRINTED IN THE UNITED STATES OF AMERICA 



T 



HE following pages contain advertisements of 
Macmillan books on kindred subjects. 



Keeping in Condition. 

By HARRY H. MOORE 

Cloth, $ 75 
This volume tells of men who have achieved the vigor of man- 
hood by faithful training. It deals with the selection of wise 
exercise and proper foods, with the providing of sufficient rest and 
fresh air, and with the control of the sex instinct. While it is 
desirable to train at certain periods for particular kinds of ath- 
letics, a wiser way, the author explains, is to keep in training, in 
the best possible condition, all the time. It describes how the 
spark of life is passed on from generation to generation, the 
relationship of training to the progress of the race and the prog- 
ress of the nation. Intended primarily for boys 14 to 19 years 
of age, it will be found useful to parents, teachers, club leaders 
and all associated with boys. 

" Mr. Moore has succeeded in an admirable way in bringing to 
youth in a chivalric fashion some of the most profound truths 
of life. The message of the book represents a forward and up- 
ward step toward that ideal goal in which the facts of physical 
function are related to the higher mental and moral development 
of the individual. It ought to have a wide circulation among 
boys in the teen age." — George J. Fisher, M.D., Secretary Physi- 
cal Department, International Committee of Young Men's Chris- 
tian Associations. 

" Mr. Moore's point of attack is excellent. He has made a great 
advance over those writers who focus the limelight on the ab- 
normal and sensational side of sexual life. He has done a good 
work." — Maurice A. Bigelow, Ph.D., Professor of Biology, Co- 
lumbia University, New York. 



THE MACMILLAN COMPANY 

Publishers 64-66 Fifth Avenue New York 



Safeguards for City Youth at Work 
and at Play. 



By LOUISE de KOVEN BOWEN. With a preface by JANE 
ADDAMS. 

241 pp., i2mo, $1.50 
A graphic description of the sordid and careless conditions 
under which thousands of young people habitually live, and of 
the efforts of a group of citizens to enlist public agencies to 
provide protection. Mrs. Bowen is president of the Juvenile 
Protective Association, and many of the matters of which she 
writes have come within her own experience. 



District Nursing. 



By MABEL JACQUES. With an Introduction by DR. JOHN 
H. PRYOR. 

Cloth, i2m,o, $1.00 
Despite the great benefits which have resulted from district 
nursing, the public knows little, either of the organization or of 
the extent of the movement. It is to inform the great mass of 
readers who are interested in social advance that Miss Jacques 
has written District Nursing. The book is provided with a 
splendid Introduction by Dr. John H. Pryor. 



THE MACMILLAN COMPANY 

Publishers 64-66 Fifth Avenue New York 



School Hygiene. 



By FLETCHER B. DRESSLAR, Bureau of Education, Wash- 
ington, D. C. 

Cloth, i2mo, III., 388 pages, $1.25 
A practical and up-to-date treatment of school hygiene and 
sanitation. A comprehensive outline with the points of depart- 
ure and direction of progress clearly indicated. Suggestive ques- 
tions and extended bibliography in connection with each chapter. 
" One of the great educational problems of the day," says the 
Boston Transcript, " is to make school life wholesome and 
healthful and to instruct all pupils in the art of living under 
decent conditions." It is with this phase of education that 
Dresslar's School Hygiene is concerned. " No committee en- 
trusted with the difficult task of erecting a new school house," 
continues the Transcript, " can well afford to neglect Dr. Dress- 
lar's advice or fail to put into practice the principles he enunci- 
ates. The author is an expert in the field of hygiene." From 
many similar press comments we quote the Chicago Evening Post 
as follows : " Dr. Dresslar of the United States Bureau of Edu- 
cation has given us the most satisfactory manual yet published 
upon the various problems pertaining to the health of the school 
child. Though it is written especially for those who are engaged 
in the management of schools, it is well fitted for general reading 
and deserves actual study by all parents and all those who pay 
school taxes." 



School Hygiene. 



By the late EDWARD R. SHAW, formerly Professor of the 
Institutes of Pedagogy, New York University. 

Cloth, i2mo, 260 pages, $1.00 
In this work the author has set forth the conditions which 
should surround pupils at school, in order that their mental and 
physical health may be thoroughly protected. He holds that it 
is in the highest degree incumbent upon school authorities to 
provide the best attainable conditions, not only to protect but 
also to promote the health of pupils committed to their care. 
The book contains a thoroughly practical discussion of school 
sanitation and hygiene. 



THE MACMILLAN COMPANY 

Publishers 64-66 Fifth Avenue New York 



Outlines of Sociology. 



By FRANK W. BLACKMAR, Ph.D., Professor of Sociology 
and Economics in the University of Kansas, and JOHN 
LEWIS GILLIN, Ph.D., Associate Professor of Sociology 
in the University of Wisconsin. 

586 pp., 8vo, $2.00 

A unified survey of the entire field of sociology particularly 
well adapted for introductory college courses. Theoretical phases 
of the subject are fully treated, and its practical bearings devel- 
oped in chapters on social pathology and the methods of social 
investigation. The inclusion of the latter serves to vitalize the 
study of sociology by giving the student an opportunity to make 
a first hand study of society, while supplying him with a few 
simple principles to guide him in the work. 

To assist the instructor in making clear the main divisions of 
the subject, the book is divided into parts under the following 
headings : 

Part I, The Nature and Import of Sociology. II, Social Evo- 
lution. Ill, Socialization and Social Control. IV, Social Ideals 
and Social Control. V, Social Pathology. VI, Methods of So- 
cial Investigations. VII, The History of Sociology, 



An Introduction to Eugenics. 

By WILLIAM CECIL DAMPIER WHETHAM, M.A., F.R.S., 
Fellow and Tutor of Trinity College, Cambridge, and 
CATHERINE DURNING WHETHAM. 

Paper, 66 pp., 8vo, $ .40 

Opens this immense field of inquiry and leads the reader to 
realize the almost oppressive importance that must be attached 
to a right solution of the problems at issue. 



THE MACMILLAN COMPANY 

Publishers 64-66 Fifth Avenue New York 



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